Personal Prevention ChartUse this Personal Prevention Chart to keep track of the preventive care that you have received and/or will need in the future. With the help of your health care provider, fill in how often you need each type of preventive care. Write in the date and results of tests each time you receive preventive care. Type of Care How Often Goal Dates Results
(Example)
Blood pressure Once a month 130/70 03/03/2004 140/80 _______ _______
Blood pressure __________ _______ _________ _______ _______ _______
Cholesterol __________ _______ _________ _______ ______ _______
Weight __________ _______ _______ _______ _______ _______ Healthy weight for me: __________ Check here Dental Visits ____________ _______ _______ _______ _______ _______ Vision ____________ _______ _______ _______ _______ _______
Return to Regular Checkups: Teeth and Gums, Cholesterol, Oral Cancer Return to Personal Prevention Charts Return to Contents of Staying Healthy at 50+
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