ADULT 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]