Personal Health Guide

This article is will serve you better if you print it out
Personal Information

Name:_______________________________________________________

Address:____________________________________________________

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Telephone:__________________________________________________

In An Emergency
Contact:____________________________________________________

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Allergies:__________________________________________________

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Important Medical Problems:_________________________________

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Clinician(s)
Phone Number(s):____________________________________________

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Medical Insurance Number(s):________________________________

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The Personal Health Guide

Working with your clinician to stay well is as important as getting treatment when you are sick. This Personal Health Guide will help you and your clinician make sure that you get the tests, immunizations (shots), and guidance you need to stay healthy.

How to Use the Personal Health Guide

Read the important information at the top of each page. Also read the yellow sections labeled "For You" and fill in the: blanks. Your answers will help clinician know what preventive care: you need. If you don't understand something, be sure to ask your clinician about it.

Fill out the blue section of each page with the help of your clinician. This will assist in the planning of your preventive care.

Use the Personal Prevention Record in the center of this Health Guide to keep track of your preventive care. Take this Health Guide home and keep it in a safe place. Look at it often to make sure that you get the preventive care you need. Bring it with you every time you see a clinician.

Weight

Weighing too much or too little can lead to health problems. You should have your weight checked regularly by your clinician. He or she can tell you what is a healthy weight for you and how to get to and stay at that weight. See pages 19-20 for information on physical activity and nutrition.

For You

I weight____________ pounds.

Ways that I control my weight now are:

1.__________________________________________________________

2.__________________________________________________________

3.__________________________________________________________

With Your Clinician

A healthy weight for me is between_________ and _________ pounds.

The best ways for me to control my weight are:

1.__________________________________________________________

2.__________________________________________________________

3.__________________________________________________________

Keep track of your weight using the Personal Prevention Record in the center of this Health Guide.

Blood Pressure

Have your blood pressure checked at least every two years, and more often if it is high.

If you have high blood pressure, talk with your clinician about how to lower it by changing your diet, losing excess weight, exercising or (if necessary) taking medicine. If you need to take medicine, be sure to take it every day, as prescribed.

Getting your blood pressure under control will help protect you from heart disease, strokes and kidney problems.

With Your Clinician

My blood pressure should be lower than__________/__________

Ways that I can keep my blood pressure under control are:

1.__________________________________________________________

2.__________________________________________________________

3.__________________________________________________________

Keep track of your blood pressure using the Personal Prevention Record in the center of this Health Guide.

Cholesterol

Have your cholesterol level checked at least every five years. Too much cholesterol can clog your blood vessels and cause heart disease and other serious problems. If your cholesterol is high, your clinician can tell you how to lower it by changing your diet, losing excess weight, exercising and (if necessary) taking medicine. Your clinician may also wish to check your levels of "bad" (LDL) and "good" (HDL) cholesterol.

For You

I last had my cholesterol checked__________ years ago.

My cholesterol was__________ mg/dL.

With Your Clinician

My cholesterol should be checked every__________ year(s). Next due__________.

My cholesterol should be less than__________ mg/dL.

Ways that I control my cholesterol are:

1.__________________________________________________________

2.__________________________________________________________

3.__________________________________________________________

Keep track of your cholesterol using the Personal Prevention Record in the center of this Health Guide.

Immunizations

Adults need immunizations ("shots") to prevent serious diseases. You should get a tetanus-diphtheria shot every ten years. At age 65 you should get a pneumococcal ("pneumonia") shot and begin having influenza ("flu") shots every year.

For You

Tell your clinician if you are a public safety or health care worker, receive blood transfusions or other blood products, engage in male homosexual activity, or use illegal drugs. You may need immunizations against hepatitis.

Also tell your clinician if you have heart, lung, kidney or liver disease, diabetes, sickle cell anemia, immune system problems (including HIV infection), Hodgkin's disease, lymphoma, multiple myeloma or if you are a public safety or health worker. You may need influenza or pneumococcal shots before age 65.

With Your Clinician

Keep track of the immunizations you receive using the Personal Prevention Record in the center of this Health Guide.

Immunization Information

For Parents

Immunizations are very important to protect your children from many types of disease. Be sure to get all of these immunizations for your children at the ages shown below. Don't be late!

For Children

Polio (OPV)--2, 4, 6 months and 4-6 years.

Diphtheria-Tetanus-Pertussis (DTP, DTaP)--2, 4,6, 15 months and 4-6 years. Also a tetanus-diphtheria (Td) shot at 15 years.

Measles-Mumps-Rubella (MMR)--12-15 months and 4-6 years, OR 11-12 years.

Haemophilus influenzae type b (Hib)--2, 4, 6 and 12-15 months, OR 2, 4 and 1215 months, depending on vaccine type.

Hepatitis B (HBV)-- Birth, 1-2 months and 6-18 months, OR 1-2 months, 4 months and 6-18 months.

Chickenpox (VZV)--12-18 months.

Oral Health Care

Good oral health care is important for your teeth and general health. With proper care, your teeth will last you for life.

Visit your dentist regularly for checkups.

Brush after meals with a soft or medium-bristled toothbrush, using a toothpaste with fluoride.

Use dental floss daily.

Limit the amount of sweets you eat, especially between meals.

Do not smoke or chew tobacco products.

For You

Date of my last visit to the dentist was__________.

With Your Dentist

I need to visit my dentist every__________ month(s)/year(s). Next due__________.

Ways that I can improve my dental health are:

1.__________________________________________________________

2.__________________________________________________________

3.__________________________________________________________

Breast Examination

For Women

You should have your breasts examined regularly by your clinician for lumps and other signs of cancer. You may want to check your own breasts for problems. Talk with your clinician about how often you need breast examinations and about doing breast self-exams.

I last had a breast exam by my clinician__________ year(s) ago.

Tell your clinician if you notice a lump in your breast, any liquid coming from the nipple or any change in the appearance of your breast.

With Your Clinician

I need breast examinations by my clinician every__________ year(s). Next due__________.

Keep track of breast examinations using the Personal Prevention Record in the center of this Health Guide.

Mammogram

For Women

You should begin having mammograms regularly by age 50. Some women may need mammograms earlier. A mammogram is an x-ray test that can detect a breast cancer when it is so small that it cannot be felt, and when it can be most easily cured. Talk with your clinician about when to begin and how often to have this important test.

I last had a mammogram__________ year(s) ago.

Tell your clinician if your mother or a sister has had breast cancer. You may need to have mammograms earlier and more often than other women.

With Your Clinician

I need a mammogram every__________ years starting at age_______. Next due__________.

Keep track of your mammograms using the Personal Prevention Record in the center of this Health Guide.

Pap Smear

For Women

You need to have Pap smears regularly. This simple test has saved the lives of many women by detecting cancer of the cervix early--when it is most easily cured.

Talk with your clinician about how often you need this very important test.

I last had a Pap smear__________ years ago.

Tell your clinician if you have had genital warts, sexually transmitted diseases (V.D.), multiple sexual partners or abnormal Pap smears. You may need Pap smears more often than other women.

With Your Clinician

I need a Pap smear every__________ year(s). Next due__________.

Keep track of your Pap smears using the Personal Prevention Record in the center of this Health Guide.

Additional Preventive Care

Below is a list of additional types of preventive care that you may need, and the personal, family and medical characteristics that may make them important for you.

With Your Clinician

Review this list with your clinician and decide what additional preventive care you need. Keep track of this additional preventive care using the Personal Prevention Record in the center of this Health Guide.

Rectal Examination, Stool Blood and Sigmoidoscopy Tests--If you are 50 years of age or older, particularly if you have had colon polyps, family members with colon cancer or have had breast, ovarian or uterine cancer yourself.

Prostate Examination--If you are a man 50 years of age or older.

Testicular Examination--If you are a man aged 15-35 years, particularly if you have had an atrophic or undescended testicle.

Mouth Examination--If, now or in the past, you have consumed a lot of alcohol or have smoked or chewed tobacco. Thyroid Examination--If you have had radiation treatments of your upper body.

Skin Examination--If you have had skin cancer in your family or a lot of sun exposure.

AIDS (HIV) Test-If you had a blood transfusion between 1978 and 1985, have injected illegal drugs, have had multiple sexual partners or any male homosexual activity.

Syphilis, Gonorrhea or Chlamydia Tests--If you have had multiple sexual partners or any sexually transmitted diseases. Tuberculosis Test--If you have injected illegal drugs, have been an alcoholic or a health care worker, have been exposed to someone with tuberculosis, have recently moved from Asia, Africa, Central or South America, or the Pacific Islands, or if you have kidney failure or HIV infection.

Glucose Test--If you have had a family member with diabetes or have had diabetes during pregnancy.

Eye Examination--If you are over age 60, over age 40 and black, or have diabetes (at any age).

Estrogen Therapy--If you are a woman who has started menopause, particularly if you .have a slender build or are white or Asian.

Aspirin Therapy--If you are a man 40 years of age or older, particularly if you have diabetes, high blood pressure, high cholesterol, early heart disease in your family, or if you smoke.

Personal Prevention Record

This Personal Prevention Record will help you keep track of the preventive care that you have received or will need in the future. With the help of your clinician, fill in how often you need each type of preventive care. For some types of preventive care, you may want to fill in a goal. Write in the date each time you receive preventive care. You may use the remaining space in each box to record other information (such as results of tests and the clinician's or clinic's name).

Type of Preventive care. Enter dates, Results and Other Information Below

Weight:__________ Date:_________

Every_____ months/years
Goal_____ lbs.

Blood Pressure:__________ Date:_________

Every_____ months/years
Goal_____/_____

Cholesterol:__________ Date:________

Every_____ months/years
Goal_____ mg/dL

Tetanus (Td) Shot Date:___________
Every 10 years

Pneumococcal Shot Date:_________
Once at age 65

Influenza Shot Date:_________
Every year starting at 65

Dental Visits Date:_________
Every_____ months/years

Preventive Care For Women

Type of Preventive Care Enter Dates, Results and Other Information Below

Breast Exam Date:________
By Clinician
Every_____ Year(s)

Mammogram Date:________
Every_____ Year(s)

Pap Smear Date:________
Every Year(s)

Additional Preventive Care

Date:_________
Every_____ months/years

Date:________
Every_____ months/years

Date:________
Every_____ months/years

Date:_______
Every_____ months/years

Smoking

Don't smoke. If you smoke, quit. It is the best thing you do to stay healthy. Ask your clinician to help you pick a date to quit and for advice on how to keep from starting again. If you fail the first time, don't give up. Keep trying and learn from your experience. You can succeed and live a healthier, longer life.

For You

I have smoked_____ packs of cigarettes each day for years.

With Your Clinician

Three reasons to quit smoking are:

1.__________________________________________________________

2.__________________________________________________________

3.__________________________________________________________

I will quit smoking on:________________________________

When I want a cigarette, I will do these things instead:

1.__________________________________________________________

2.__________________________________________________________

3.__________________________________________________________

Physical Activity

All kinds of physical activity will help you feel better and maintain a healthy weight. Regular physical activity will also help you control your blood pressure and cholesterol, and strengthen your heart and muscles. Even daily activities such as housework, walking, or raking leaves will help. Pick activities that you enjoy, that fit into your daily routine, and that you can do with a Mend. Try for a total of 30 minutes per day, 5 days per week.

For You

Ways that I now get regular physical activity are:

1.__________________________________________________________

2.__________________________________________________________

3.__________________________________________________________

With Your Clinician

Ways that I can get more regular physical activity are:

1.__________________________________________________________

2.__________________________________________________________

3.__________________________________________________________

Nutrition

Eating the right foods will help you live a longer, healthier life. Many illnesses such as diabetes, heart disease, and high blood pressure can be prevented or controlled through a healthy diet. It is never too late to start eating right. Follow the simple guidelines below.

Dietary Guidelines for Americans

Eat a variety of foods.

Maintain a healthy weight.

Choose a diet low in fat, saturated fat and cholesterol.

Choose a diet with plenty of vegetables, fruits and grain products.

Use sugars only in moderation.

Use salt and sodium only in moderation.

If you drink alcoholic beverages, do so only in moderation (no more than 1 drink daily for women and 2 drinks daily for men).

Safety

Many serious injuries can be prevented by following basic safety rules.

Always wear safety belts while in a car.

Never drive after drinking alcohol.

Always wear a safety helmet while riding on a motorcycle or bicycle.

Use smoke detectors in your home. Change batteries every year and check to see that they work every month.

Keeping a gun in your home can be dangerous. If you do. make sure that the gun and the ammunition are locked up separately.

Keep the temperature of your hot water less than 120�F. This is especially important if there are children or older adults living in your home.

Prevent falls by older adults. Repair slippery or uneven walking surfaces, improve poor lighting and install secure railings on all stairways.

Be alert for hazards in your workplace and follow all safety rules.

AIDS

AIDS (Aquired Immunodeficiency Syndrome) is a fatal disease that breaks down the body's ability to fight infection and illness. AIDS is caused by a virus(HIV). (By preventing HIV infection, you can prevent AIDS. Many different kinds of people have AIDS--male and female, married and single, rich and poor. There is currently no cure for AIDS and no vaccine to prevent HIV infection.

How Do You Get HIV?

Most people with HIV got infected by having sex with an infected partner. Many others got HIV when they shared needles to take drugs.

You cannot get infected with HIV from shaking hands with someone who has it, from working with someone who has it or from volunteering to help people with AIDS.

How To Reduce Your Risk Of Getting HIV

* You can reduce your risk of getting HIV by not having sex, by having sex with only one, mutually faithful, uninfected partner or by using a latex condom correctly every time you have sex.
* You can reduce your risk of getting HIV by not shooting drugs or sharing needles and syringes.

Family Planning

The birth of a child is a joyful event. However, it is best to have children when you are prepared to take care of them. If you are a sexually active man or woman and not ready to have a child, you should use a reliable method of contraception. Some of the different methods of contraception and their effectiveness in typical use over one year are listed below Talk with your clinician about the best method of contraception for you.

Methods of Contraception

Reversible Methods

* Medications--birth control pills (97% effective), implants (over 99%), and shots (over 99%)

* Intrauterine Devices (IUDs)--(98%)

* Barrier Methods--condoms (88%), diaphragms (82%), cervical caps (64-82%), and vaginal sponges (64%-82%)

* Natural Family Planning Methods---(80%)

* Spermicides (alone)--foams and suppositories (79%)

Permanent Methods

* Sterilization--vasectomy (over 99%) and tubal ligation (over 99%)

Alcohol and Drug Abuse

Don't use illegal (street) drugs of any kind, at any time.

Use prescription drugs only as directed by a clinician. Use non-prescription drugs only as instructed on the label.

If you drink alcohol, do so only in moderation--no more than I drink daily for women and 2 drinks daily for men.

Do not drink alcohol at all if you are pregnant or may be in the near future.

Do not drink alcohol before or while driving a motor vehicle.

If you have a problem with alcohol or drugs, see your clinician.

Read the questions below. A "Yes" answer to any of these questions may be a warning sign that you have a drinking problem.

* Have you ever felt that you should cut down on your drinking?

* Have people annoyed you by criticizing your drinking?

* Have you ever felt bad or guilty about drinking ?

* Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

Depression

We all feel "down" or "blue" at times. HoWever. if these feelings are very strong or last for a long time, they may be due to a medical illness--depression.

This illness can be treated, but it is often not recognized by patients and clinicians. Some of the warning signs of depression are listed below. If you have four or more of these warning signs, you should be sure to talk with your clinician about depression.

Warning Signs of Depression

* Feeling sad, hopeless or guilty

* Loss of interest and pleasure in daily activities

* Sleep problems (either too much or too little)

* Fatigue, low energy, or feeling "slowed down"

* Problems making decisions or thinking clearly

* Crying a lot

* Changes in appetite or weight (up or down)

* Thoughts of suicide or death

For More Information

If you would like to learn more about how to stay healthy and prevent disease, you should talk with your clinician or the local health department You may also obtain information by calling the telephone numbers listed below, most of which are toll-free.

Aging
National Council on Aging
(202) 479-1200

AIDS
CDC National AIDS Hotline
(800) 342-AIDS

Alcohol and Drug Abuse
National Clearinghouse for Alcohol
and Drug Information
(800) 729-6686

Cancer
Cancer Information Service
(800) 4-CANCER

Child Abuse
National Child Abuse Hotline
(800) 422-4453

Food and Drug Safety
Food and Drug Administration,
Office of Consumer Affairs
(301) 443-3170

Heart, Lung and Blood Diseases
National Heart, Lung and Blood
Institute, Information Center
(301) 251-1222

Maternal and Child Health
National Maternal and Child Health
Clearinghouse
(703) 821-8955 ext. 254

Mental Health
National Mental Health Association
(800) 969-6642

Occupational Safety and Health
National Institute for Occupational
Safety and Health
(800) 356-4674

Physical Activity and Fitness
Aerobic and Fitness Foundation
(800) BE FIT 86

Safety and Injury Prevention
Consumer Product Safety Commission
(800) 638-CPSC

National Highway Traffic Safety
Administration, Auto Safety Hotline
(800) 424-9393

Sexually Transmitted Diseases
CDC National STD Hotline
(800) 227-8922

Medication Record

Name:
Dose:
How Often:

Date(s) Last Reviewed By Clinician:

Notes

Put Prevention Into Practice

"Put Prevention Into Practice" is a national initiative of the U.S. Department of Health and Human Services' Public Health Service in partnership with public and private health care organizations.*

The goal of "Put Prevention Into Practice" is to preserve the health of all Americans by improving the preventive care they receive.

You can help to put prevention into practice by working with your health care providers to make sure you get all the preventive care you need.

You can also do your part by following the health advice in this Personal Health Guide. Take charge of your health and live a longer and healthier life!

For more information about the "Put Prevention Into Practice" campaign, write: Put Prevention Into Practice, National Health Information Center, PO. Box 1133, Washington, DC 20013-1133.

* Neither the Public Health Service nor the U.S. Department of Health and Human Services endorses any particular product, service or organization.

* U.S. G.P.O.: 1994-365-753 (Item #2)

This publication was developed by the U.S. Federal Government and is in the public domain. Duplication is encouraged subject to the following conditions: The material must appear in its entirety and it must be identified as developed by the U.S. Department of Health and Human Services. If your organization is identified on copies and/or supplemental information is incorporated, then all supplemental pages must be labeled "(Your organization) Supplement" and the following disclaimer must appear within the publication: "Neither the Public Health Service nor the U.S. Department of Health and Human Services endorses any particular organization, product, or service."

For more information about the Put Prevention Into Practice campaign, write:

Put Prevention Into Practice
National Health Information Center
P.O. Box 1133
Washington, DC 20013-1133

Information provided by the NIH.