A preventive care checklist is what a family physician or nurse practitioner works through at an adult periodic health review: the screening, vaccines, and counselling due for this patient’s age, sex, and risk, and when each comes due again. Copy the free checklist, see a 52-year-old man in Ontario and a 67-year-old woman in British Columbia, and check the national and provincial guidance behind each line.
For clinicians in Canada.
Blank adult preventive care checklist template
FreeADULT PREVENTIVE CARE CHECKLIST Patient: [Name, age, sex at birth, and gender if different] Province: [Province or territory, which sets the screening programs and funded vaccines] Visit date: [Date] Clinician: [Name, credentials] Last periodic health review: [Date, or none on file] Risks that change the schedule: [Family history of early cancer, pack-years, immunocompromise, pregnancy plans, or none] Status key: done today, ordered, up to date, due, declined, or not indicated. Give every line its next due date. CARDIOMETABOLIC Blood pressure: [Reading today, a repeat if high, and home readings if any] Weight and waist: [Weight in kg, BMI, waist in cm] Diabetes risk: [FINDRISC or CANRISK score; A1c with its date if the score is high] Lipids: [Last profile and date, LDL-C in mmol/L, and the cardiovascular risk score] CANCER SCREENING Colorectal: [FIT date and result, or colonoscopy and its repeat interval; the provincial starting age] Breast: [Last mammogram, result, and next date from the provincial program, or not applicable] Cervical: [HPV test or Pap test, date, result, and when screening can stop, or not applicable] Lung: [Pack-years, quit date if former, and whether low-dose CT applies from 55] Prostate: [PSA discussed if raised, and the patient's choice] OTHER SCREENING Bone health: [Women 65 and older: FRAX risk without BMD, and whether she wants BMD to decide on treatment] Abdominal aortic aneurysm: [Men 65 to 80: one-time ultrasound date and result, or not applicable] Hepatitis C: [Risk factors asked, and the test date and result if at risk] Sexually transmitted infections: [Under 30 and sexually active: chlamydia and gonorrhea yearly; other tests by risk] IMMUNIZATIONS Influenza: [This season's dose, product, date, and where, or declined] COVID-19: [Last dose and date, and the doses due this season for age and risk] Tetanus, diphtheria, pertussis: [Adult Tdap date; last Td and the next one due 10 years later] Pneumococcal: [Pneu-C-20 or Pneu-C-21 date, or why it is due: 65 or older, or a risk factor] Shingles: [RZV dose 1 and dose 2 dates, from age 50] RSV: [75 and older, or 65 to 74 with a risk condition: given, offered, or the patient's choice] HPV: [Doses on record; catch-up to 26, or a shared decision from 27] Other vaccines: [Hepatitis B, MMR, travel, or work vaccines due] Record checked: [Clinic chart, provincial registry, pharmacy, or the patient's own card] LIFESTYLE AND COUNSELLING Tobacco and vaping: [Never, former with quit date, or current with pack-years and readiness to quit; help offered] Alcohol: [Standard drinks a week and the most on one day] Cannabis and other substances: [Type and how often, or none] Activity, eating, and sleep: [Minutes of moderate to vigorous activity a week, strength days, balance work from 65; usual eating pattern; hours of sleep] Mood and stress: [How the patient is coping, asked in conversation, and any follow-up] Goal chosen: [The one change the patient picked, in numbers] OLDER ADULTS, 65 AND OVER Falls: [Falls in the past year, injuries, fear of falling, and a gait check if there was a fall] Hearing: [Concerns from the patient or family, hearing aids, referral] Vision: [Concerns, last eye exam, night driving] Cognition: [Only when the patient, family, or you are concerned: what was noticed and the next step] Advance care planning: [Substitute decision-maker, wishes discussed, or offered] PLAN Done today: [Vaccines given, samples collected, kits handed out] Ordered or referred: [Labs, FIT, imaging, programs, and who follows up the results] Declined: [Each item, the reason, and when to offer it again] Next due: [Each item with its month and year] Next periodic health review: [Date or interval] Patient profile updated: [Date] Signed: [Clinician name, credentials, date]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Family health team in Ontario, periodic health review
52-year-old man, truck dispatcher. Last periodic health review in 2021. Smokes a pack a day since age 18: 34 pack-years. Father: type 2 diabetes at 58 and a heart attack at 66. No colorectal cancer in the family. No regular medicines. No known drug allergies.
BP 134/86, repeat 130/84 after 5 minutes’ rest; no home readings. Height 178 cm, weight 92 kg, BMI 29.0, waist 104 cm. FINDRISC 15, high risk: age, BMI, waist, less than 30 minutes of activity a day, vegetables most days but not daily, and his father’s diabetes. A1c never done. Lipids last checked in 2019. Due: A1c and a non-fasting lipid profile.
Colorectal: never screened, and Ontario’s program now starts at 45. FIT ordered; repeat every 2 years if normal. Lung: not yet. At 55 he can be referred to the Ontario Lung Screening Program. Prostate: he asked about a PSA test. Went through the Task Force advice against screening, and the chance of a false positive leading to a biopsy; he chose not to test. Bone health and aortic aneurysm: not at his age. Hepatitis C: has never injected drugs or been in prison; not tested. STI: one partner for 20 years; not indicated.
Influenza: given today. COVID-19: last dose in 2023; offered, declined. Td at a walk-in clinic in 2014 for a cut; no adult pertussis dose on record, so Tdap given today, and Td next due in 2036. Shingles: RZV dose 1 given today, paid by his workplace drug plan; dose 2 in 2 to 6 months. Pneumococcal: smoking is a risk factor in the Canadian Immunization Guide, particularly after 50, so Pneu-C-20 is due; booked for his next visit. Record checked: clinic chart and his pharmacy’s record.
Smoking: wants to quit before his daughter’s wedding in May; tried patches alone in 2020 and lasted a week. Starting varenicline 0.5 mg once a day for 3 days, then 0.5 mg twice a day for 4 days, then 1 mg twice a day for 12 weeks; quit date December 1. Referred to a quit-smoking counsellor. Alcohol: 8 to 10 beers a week, up to 4 on a Saturday; he chose no more than 4 a week and 2 on any day. Activity: desk job, no planned exercise; left for the next visit so the quit attempt comes first. Mood: busy but coping.
Done today: influenza, Tdap, RZV dose 1. Ordered: FIT, A1c, lipid profile; results by phone. Started: varenicline, quit date December 1; counsellor referral sent. Declined: PSA, and COVID-19 this fall. Next due: Pneu-C-20 and a smoking check-in in 2 weeks; RZV dose 2 between January and May 2027; cardiovascular risk score when the lipids are back; lung screening referral at 55, in 2029; Td in 2036. Next periodic health review: November 2027. Patient profile updated November 10, 2026.
Family practice in Kelowna, British Columbia, periodic health review
67-year-old woman, retired teacher, lives with her husband. Last review in 2024. Hypothyroidism on levothyroxine 75 mcg daily. No heart, lung, liver, or kidney disease, and no diabetes. Her mother broke a hip at 79. Never smoked. No known drug allergies.
BP 124/76. Height 163 cm, weight 58 kg, BMI 21.8, waist 82 cm. FINDRISC 7: no diabetes screening. Lipids in 2024: LDL-C 2.9 mmol/L, Framingham risk low; next profile in 2029.
Breast: last mammogram October 2024, normal; due now at BC Cancer’s 2-year interval, and she will book it herself. Cervical: last Pap test normal in 2021; no HPV test yet. HPV self-collection kit given; under BC’s program, an HPV-not-detected result at 65 to 69 means she can stop cervical screening. Colorectal: FIT negative in May 2025; next due May 2027. Lung: never smoked; not indicated.
No fractures. Canadian FRAX without BMD calculated with her, counting her mother’s hip fracture, and the result recorded in the chart. Went through the Task Force decision aid; she would consider medication, so a DXA of the femoral neck is booked to recalculate her risk. Aortic aneurysm: not screened in women. Hepatitis C: no risk factors.
Influenza: high-dose vaccine, October 2026, at her pharmacy. COVID-19: one dose in October 2026, which is what NACI strongly recommends at her age and risk. Tdap in 2019; Td due 2029. Shingles: RZV, 2 doses in 2023, complete. Pneumococcal: Pneu-P-23 at 65, in 2024; the guide now advises one dose of Pneu-C-20 or Pneu-C-21 at least a year later, so Pneu-C-20 given today. RSV: strongly recommended at 75, or at 65 to 74 with a condition that raises risk; she has none, so it is her choice. She chose to wait.
Walks 40 minutes a day; no strength or balance work. Alcohol: 5 or 6 glasses of wine a week, never more than 2 in a day; she chose to keep wine to weekends, about 3 glasses a week. Eats well; sleeps 7 hours. Enjoying retirement; looks after her grandchildren twice a week.
Falls: one fall on an icy driveway in January, a bruised hip, no fracture; steady since. Timed Up and Go 10 seconds, no unsteadiness. Referred to a community strength and balance class, twice a week. Hearing: struggles to follow talk in busy restaurants; referred for a hearing test. Vision: optometrist in June 2026, early cataracts, no trouble driving at night. Cognition: no concerns from her or her husband; not tested. Advance care planning: her husband is her representative under a representation agreement signed in 2022.
Done today: Pneu-C-20; HPV kit handed out. Booked: DXA, mammogram, hearing test, balance class. Decided: RSV vaccine deferred by her choice, to revisit at 75, in 2034, or sooner if a risk condition develops. Next due: FIT May 2027; Td 2029; lipids 2029. Visit after the DXA for her result and the treatment decision. Next periodic health review: November 2027. Patient profile updated November 10, 2026.
Screening follows the Canadian Task Force on Preventive Health Care. Its mandate ended on March 31, 2026, and its guidelines remain online; the National Advisory Committee on Preventive Health Services replaced it in June 2026. Vaccines follow the Canadian Immunization Guide and NACI. Provinces run their own programs, and some now screen earlier or with other tests, as the Ontario and BC rows show.
Age, sex at birth, province, and a few risks decide almost every line below. Write them first, so the rest of the checklist follows from them.
Avoid: Assuming average risk without asking. In Ontario’s program, one parent with colon cancer before 60 means colonoscopy from 40, or 10 years before the parent’s diagnosis, whichever comes first, in place of FIT.
Blood pressure at every appropriate visit, diabetes by a risk score, and lipids from 40, each with the number and its date.
Avoid: An A1c for everyone because it’s a checkup. The Task Force ties diabetes screening to the risk score, so write the score that justified the test.
Colorectal, breast, cervical, and lung screening by age and risk. Give each one its last date, result, and next due date, under your province’s program.
Avoid: A schedule printed years ago. Since 2024 provinces have lowered starting ages and switched cervical screening to HPV tests, so check your program’s current rules.
Bone health, aortic aneurysm, hepatitis C, and sexually transmitted infections, each for a defined group only.
Avoid: Ordering bone density first. The Task Force puts risk assessment first and BMD second, only when the patient would consider treatment.
Every adult vaccine with its date, checked against the Canadian Immunization Guide and then your province’s funded schedule.
Avoid: Relying on memory for dates. Many adults now get influenza, COVID-19, and shingles vaccines at a pharmacy; check the pharmacy record or the provincial registry.
Smoking, alcohol, activity, and eating, each with a number, and the one goal the patient picks.
Avoid: Topics with no numbers. “Counselled re smoking” can’t be followed up; “34 pack-years, ready to quit, varenicline started, quit date December 1” can.
From 65, add falls, hearing, vision, and planning ahead. Assess cognition only when someone is concerned.
Avoid: A memory test at every review after 65. Without a concern the Task Force advises against it; with one, it’s an assessment that needs its own visit.
The Task Force advises against PSA screening, routine vision screening from 65, memory tests without a concern, and questionnaire screening for depression. A test with no indication can start a chain of follow-up the patient didn’t need.
A line is only useful if it says when the item comes back. “FIT negative May 2025, next May 2027” lets the next clinician, or a recall list, act on it.
Cervical screening follows the cervix, whatever the patient’s gender. Record sex at birth and relevant surgeries, and check your program’s guidance for breast screening in trans and nonbinary patients.
Write what the patient declined, why, and when to offer it again. Preferences change, and a reason recorded today saves the conversation starting from scratch next year.
Vero Scribe drafts the checklist in your template from the visit, with the patient’s consent, or from your dictation. You review and edit every line, then copy it into your EMR or export it to Word or PDF. Vero works in 60+ languages.
A list of the screening tests, vaccines, and counselling an adult is due for at a periodic health review, set by age, sex, and risk. Each line gets a status and a next due date, so the review ends with a plan rather than a vague “up to date.” In Canadian family practice its due dates also feed the reminders in the cumulative patient profile.
No. The College of Family Physicians of Canada endorses the Preventive Care Checklist Form, in male and female versions for average-risk adults, last updated in June 2018. It is copyrighted, so it isn’t reproduced here. This checklist is Vero’s own, written from the Task Force guidelines, the Canadian Immunization Guide, and NACI statements, including guidance published since 2018, such as the 2023 fracture guidance and RSV vaccines for older adults.
An annual physical exam note records the whole visit: history, review of systems, examination, and plan. This checklist covers prevention only: what is due, what was done, and when each item comes back. Use it inside the visit note, or on its own at a prevention visit with a nurse.
Provinces run their own screening programs and fund their own vaccines, on their own timelines. Ontario now starts colorectal screening at 45; Ontario and British Columbia take breast screening self-referrals from 40 and screen the cervix with an HPV test every 5 years. Where they differ, write the national guidance, your province’s rule, and the choice the patient made.
Yes. Copy it, or download it as a Word or text file. No account needed.
The preventive visit: interval history, screening and vaccines due, full exam, and counseling.
The Medicare AWV, G0438 and G0439: health risk assessment, cognition, screening schedule, risk factors, and the prevention plan.
The one-time IPPE, G0402: history, depression and safety review, exam with visual acuity, end-of-life planning, and the written plan.
The standing summary at the front of the chart: problems, history, medications, allergies, immunizations, risks, and reminders, kept current.
The first visits after arrival: interpreter, journey, IFHP coverage, catch-up vaccines, screening by region, mental health, and social needs.
Screening, vaccines, and counselling, drafted from the visit for your review.
Visits with several concerns, and chart updates, drafted from the conversation.
The codes used most often in family medicine and primary care.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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