255 Main Street Unionville, Unionville, Ontario L3R 2H3, Canada
Appointments: (905) 477- 0027
Appointments: (905) 477- 0027
LIFESTYLE
- Physical Activity – in mins/week
recommend 150 minutes of aerobic activity weekly if no cardiac or other contraindications
- Nutrition / Diet – Scale of 0 (very poor) – 10 (excellent)
This is the patient's subjective scoring
o Vegetarian?
- Smoking – cigarettes / other per day:
- Alcohol – drinks per week:
- Sleep – hours per day:
- Stress Level – Scale of 0 (very low) – 10 (very high):
This is the patient's subjective scoring
- Poverty screen
Are you able to make ends meet each month?
Are you taking any prescription medications?
Have any of these changed recently?
-Allergies?
PREVENTIONS
The list for an individual is based upon both national expert consensus and individual considerations unique to each patient
- Blood Test – every 1-2 yrs. unless abnormal
OHIP only pays if it was previously abnormal
o Prior Test Date:
o Action:
- BMD – every 5 yrs unless abnormal
o Prior Test Date:
o Action:
- Colonoscopy / FIT – until age 75
FIT every 2 years if no colonoscopy
o Prior Test Date:
o Action:
- Pap – until age 69
o Prior Test Date:
o Action:
- Mammogram – every 1-2 yrs
o Prior Test Date:
o Action:
- Pneumonia Vaccine (for patients with chronic disease)
Pneumo 23
Prevnar 13
not covered by OHIP
o Prior Vaccination Date:
o Action:
- Herpes Zoster (“Shingles”)
Zostavax or Shingrix x 2 in the past
o Prior Vaccination Date:
which one?
o Action:
- Tetanus – every 10 yrs
o Prior Vaccination/Booster Date:
o Action:
- Flu Vaccine - annual
o Prior Vaccination Date:
o Action:
- Covid – 19
o Prior Vaccination Date:
o Action
SUMMARY OF PREVENTATIVE CARE ACTION
The patient has been informed of recommended preventions and has agreed to the following:
Dr. Carson Authorization on tests, cancer screens, and vaccines to be carried out:
ADDITIONAL WELLNESS CHECK
- Vision
- Hearing
- Falls / Balance
-Memory
- Sun Exposure / Skin Care
- Vitamin and Mineral Supplements:
- Vitamin D
- Calcium/Dairy
- Salt intake
-Caffeine
-Water
Patients concerns for follow up with Dr. Carson:
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