**PREVENTIVE CARE GUIDELINES AND FLOW SHEETS**

This is a compilation of the Office of Medical Services recommendations
of guidelines for health promotion and maintenance. MED recommends
following The U.S. Preventive Services Task Force (**USPSTF**) Guide to
Clinical Preventive Services, 2007 and future updates as a mainstay of
evidence-based standard of care recommendations and The American Academy
of Pediatrics **[Bright Futures]{.underline}** Guidelines for Health
Supervision of Infants, Children, and Adolescents. To view **CDC's
updated schedules** of immunizations see the MED website/ MED
Departments/ DASHO/ Occupational Health/ Immunization Scheduler.

MED-created flow sheets would be redundant and inefficient. **MED
recommends the use of the following extrinsic flow sheet forms for
documentation of evaluations.** Please watch for updated versions!
(Forms *DS-6541*, Adolescent Health Promotion; *DS-6543*, Adult Health
Promotion Flow Sheet 18 Years and Older; *DS-6538*, Health Education and
Counseling Newborn to 2 Years; and *DS-6540*, Recommended Examinations
and Health Education Ages 3-11 Years should be deleted.)

FLOW SHEETS

The well-child pediatric forms from the web site from the State of
Washington have been excellent guides and handouts for both parents and
providers. However, they are dated to 2001. Currently the state of
Washington infant/ child/ and adolescent health promotion staff are not
planning to update the flow sheets. The state of Maine has also created
flow sheets (dated 2006) based on [Bright Futures]{.underline}
Guidelines and can be found at
[[http://www.state.me.us/bms/providerfiles/bright_future.htm]{.underline}](http://www.state.me.us/bms/providerfiles/bright_future.htm).
They can be printed and are excellent. Unless and until Bright Futures
creates flow sheets for the use and documentation of its guidelines or
other updated flow sheets become available, the Maine flow sheets ( with
minor editions) are recommended to document well visits.

For adults you can click the AHRQ website (per the above Preventive
Screening paragraph on the MED web site) at
[[http://epss.ahrq.gov/ePSS/index.jsp]{.underline}](http://epss.ahrq.gov/ePSS/index.jsp)

and go to \"Search for Recommendations.\" You can print forms by
entering ages 30, 40, 50, etc. for both men and women. You can use these
to document dates and evaluations.

GUIDELINES

The American Academy of Pediatrics [Bright Futures]{.underline} provides
guidelines (no flow sheets per se) for health supervision of infants,
children, and adolescents through the Third Edition Guide. The [Bright
Futures]{.underline} Guidelines Third Edition Pocket Guide (\$14.95 plus
shipping) or PDA (\$69.95) may be ordered at
[www.brightfutures.org](http://www.brightfutures.org/). Either format
presents a summary for each visit's developmental, physical examination,
medical screening, and immunization guidelines.

October 2008 MED/ DASHO/ Occupational Health/ Health Promotion

+-----------------------------------------------------------------------+
| +------------------------------------------------------------------+  |
| | Guide to Clinical Preventive Services, 2007                      |  |
| +------------------------------------------------------------------+  |
| | +-------------------------------------------------------------+  |  |
| | | **What the U.S. Preventive Services Task Force Grades       |  |  |
| | | Mean**                                                      |  |  |
| | |                                                             |  |  |
| | | **The U.S. Preventive Services Task Force (USPSTF) grades   |  |  |
| | | its recommendations based on the strength of evidence and   |  |  |
| | | magnitude of net benefit (benefits minus harms).**          |  |  |
| | |                                                             |  |  |
| | | **A.** The USPSTF strongly recommends that clinicians       |  |  |
| | | provide \[the service\] to eligible patients. *The USPSTF   |  |  |
| | | found good evidence that \[the service\] improves important |  |  |
| | | health outcomes and concludes that benefits substantially   |  |  |
| | | outweigh harms*.                                            |  |  |
| | |                                                             |  |  |
| | | **B.** The USPSTF recommends that clinicians provide \[the  |  |  |
| | | service\] to eligible patients. *The USPSTF found at least  |  |  |
| | | fair evidence that \[the service\] improves important       |  |  |
| | | health outcomes and concludes that benefits outweigh        |  |  |
| | | harms*.                                                     |  |  |
| | |                                                             |  |  |
| | | **C.** The USPSTF makes no recommendation for or against    |  |  |
| | | routine provision of \[the service\]. *The USPSTF found at  |  |  |
| | | least fair evidence that \[the service\] can improve health |  |  |
| | | outcomes but concludes that the balance of benefits and     |  |  |
| | | harms is too close to justify a general recommendation*.    |  |  |
| | |                                                             |  |  |
| | | **D.** The USPSTF recommends against routinely providing    |  |  |
| | | \[the service\] to asymptomatic patients. *The USPSTF found |  |  |
| | | at least fair evidence that \[the service\] is ineffective  |  |  |
| | | or that harms outweigh benefits*.                           |  |  |
| | |                                                             |  |  |
| | | **I.** The USPSTF concludes that the evidence is            |  |  |
| | | insufficient to recommend for or against routinely          |  |  |
| | | providing \[the service\]. *Evidence that \[the service\]   |  |  |
| | | is effective is lacking, of poor quality, or conflicting,   |  |  |
| | | and the balance of benefits and harms cannot be             |  |  |
| | | determined*.                                                |  |  |
| | +-------------------------------------------------------------+  |  |
| |                                                                  |  |
| | **Preventive Services Recommended by the USPSTF**                |  |
| |                                                                  |  |
| | The U.S. Preventive Services Task Force (USPSTF) recommends that |  |
| | clinicians discuss these preventive services with eligible       |  |
| | patients and offer them as a priority. All these services have   |  |
| | received an \"A\" (strongly recommended) or a \"B\"              |  |
| | (recommended) grade from the Task Force.                         |  |
| |                                                                  |  |
| |   ------------------------                                       |  |
| | ---------------------------------------------------------------- |  |
| | -------- ------------ ----------- --------------- -------------- |  |
| |   **Recommen                                                     |  |
| | dation**                                                         |  |
| |                        **Adults**               **Special        |  |
| |                                                                  |  |
| |                                                                  |  |
| |                                                 Populations**    |  |
| |                                                                  |  |
| |                                                                  |  |
| |                                                                  |  |
| |            **Men**      **Women**   **Pregnant      **Children** |  |
| |                                                                  |  |
| |                                                                  |  |
| |                                                 Women**          |  |
| |                                                                  |  |
| |   Abdominal A                                                    |  |
| | ortic Aneurysm,                                                  |  |
| |                       X                                          |  |
| |   Screening[                                                     |  |
| | ^[1]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.ht |  |
| | m#ref1%23ref1)                                                   |  |
| |                                                                  |  |
| |   Alcohol Mis                                                    |  |
| | use Screening and Behavioral Counseling Interventions            |  |
| |                       X            X           X                 |  |
| |                                                                  |  |
| |   Aspirin for                                                    |  |
| |  the Primary Prevention of Cardiovascular                        |  |
| |                       X            X                             |  |
| |   Events[^[2                                                     |  |
| | ]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.htm#r |  |
| | ef2%23ref2)                                                      |  |
| |                                                                  |  |
| |   Bacteriuria                                                    |  |
| | , Screening for Asymptomatic                                     |  |
| |                                                X                 |  |
| |                                                                  |  |
| |   Breast Canc                                                    |  |
| | er,                                                              |  |
| |                                    X                             |  |
| |   Chemopreve                                                     |  |
| | ntion[^[3]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/g |  |
| | cp1.htm#ref3%23ref3)                                             |  |
| |                                                                  |  |
| |   Breast Canc                                                    |  |
| | er,                                                              |  |
| |                                    X                             |  |
| |   Screening[                                                     |  |
| | ^[4]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.ht |  |
| | m#ref4%23ref4)                                                   |  |
| |                                                                  |  |
| |   Breast and                                                     |  |
| | Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA  |  |
| | Mutation                           X                             |  |
| |   Testing[^[                                                     |  |
| | 5]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.htm# |  |
| | ref5%23ref5)                                                     |  |
| |                                                                  |  |
| |   Breastfeedi                                                    |  |
| | ng, Behavioral Interventions to                                  |  |
| |                                    X           X                 |  |
| |   Promote[^[                                                     |  |
| | 6]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.htm# |  |
| | ref6%23ref6)                                                     |  |
| |                                                                  |  |
| |   Cervical Ca                                                    |  |
| | ncer,                                                            |  |
| |                                    X                             |  |
| |   Screening[                                                     |  |
| | ^[7]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.ht |  |
| | m#ref7%23ref7)                                                   |  |
| |                                                                  |  |
| |   Chlamydial                                                     |  |
| | Infection,                                                       |  |
| |                                    X           X                 |  |
| |   Screening[                                                     |  |
| | ^[8]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.ht |  |
| | m#ref8%23ref8)                                                   |  |
| |                                                                  |  |
| |   Colorectal                                                     |  |
| | Cancer,                                                          |  |
| |                       X            X                             |  |
| |   Screening[                                                     |  |
| | ^[9]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.ht |  |
| | m#ref9%23ref9)                                                   |  |
| |                                                                  |  |
| |   Dental Cari                                                    |  |
| | es in Preschool Children,                                        |  |
| |                                                                X |  |
| |   Prevention                                                     |  |
| | [^[10]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1. |  |
| | htm#ref10%23ref10)                                               |  |
| |                                                                  |  |
| |   Depression,                                                    |  |
| |                                                                  |  |
| |                       X            X                             |  |
| |   Screening[                                                     |  |
| | ^[11]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.h |  |
| | tm#ref11%23ref11)                                                |  |
| |                                                                  |  |
| |   Diabetes Me                                                    |  |
| | llitus in Adults, Screening for Type                             |  |
| |                       X            X                             |  |
| |   2[^[12]{.u                                                     |  |
| | nderline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.htm#ref12 |  |
| | %23ref12)                                                        |  |
| |                                                                  |  |
| |   Diet, Behav                                                    |  |
| | ioral Counseling in Primary Care to Promote a                    |  |
| |                       X            X                             |  |
| |   Healthy[^[                                                     |  |
| | 13]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.htm |  |
| | #ref13%23ref13)                                                  |  |
| |                                                                  |  |
| |   Gonorrhea,                                                     |  |
| |                                                                  |  |
| |                                    X           X                 |  |
| |   Screening[                                                     |  |
| | ^[14]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.h |  |
| | tm#ref14%23ref14)                                                |  |
| |                                                                  |  |
| |   Gonorrhea,                                                     |  |
| | Prophylactic                                                     |  |
| |                                                                X |  |
| |   Medication                                                     |  |
| | [^[15]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1. |  |
| | htm#ref15%23ref15)                                               |  |
| |                                                                  |  |
| |   Hepatitis B                                                    |  |
| |  Virus Infection,                                                |  |
| |                                                X                 |  |
| |   Screening[                                                     |  |
| | ^[16]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.h |  |
| | tm#ref16%23ref16)                                                |  |
| |                                                                  |  |
| |   High Blood                                                     |  |
| | Pressure, Screening                                              |  |
| |                       X            X                             |  |
| |                                                                  |  |
| |   HIV, Screen                                                    |  |
| | ing[^[17]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gc |  |
| | p1.htm#ref17%23ref17) X            X           X               X |  |
| |                                                                  |  |
| |   Iron Defici                                                    |  |
| | ency Anemia,                                                     |  |
| |                                                                X |  |
| |   Prevention                                                     |  |
| | [^[18]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1. |  |
| | htm#ref18%23ref18)                                               |  |
| |                                                                  |  |
| |   Iron Defici                                                    |  |
| | ency Anemia,                                                     |  |
| |                                                X                 |  |
| |   Screening[                                                     |  |
| | ^[19]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.h |  |
| | tm#ref19%23ref19)                                                |  |
| |                                                                  |  |
| |   Lipid Disor                                                    |  |
| | ders,                                                            |  |
| |                       X            X                             |  |
| |   Screening[                                                     |  |
| | ^[20]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.h |  |
| | tm#ref20%23ref20)                                                |  |
| |                                                                  |  |
| |   Obesity in                                                     |  |
| | Adults,                                                          |  |
| |                       X            X                             |  |
| |   Screening[                                                     |  |
| | ^[21]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.h |  |
| | tm#ref21%23ref21)                                                |  |
| |                                                                  |  |
| |   Osteoporosi                                                    |  |
| | s in Postmenopausal Women,                                       |  |
| |                                    X                             |  |
| |   Screening[                                                     |  |
| | ^[22]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.h |  |
| | tm#ref22%23ref22)                                                |  |
| |                                                                  |  |
| |   Rh (D) Inco                                                    |  |
| | mpatibility,                                                     |  |
| |                                                X                 |  |
| |   Screening[                                                     |  |
| | ^[23]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.h |  |
| | tm#ref23%23ref23)                                                |  |
| |                                                                  |  |
| |   Syphilis In                                                    |  |
| | fection,                                                         |  |
| |                       X            X           X                 |  |
| |   Screening[                                                     |  |
| | ^[24]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.h |  |
| | tm#ref24%23ref24)                                                |  |
| |                                                                  |  |
| |   Tobacco Use                                                    |  |
| |  and Tobacco-Caused Disease, Counseling to                       |  |
| |                       X            X           X                 |  |
| |   Prevent[^[                                                     |  |
| | 25]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.htm |  |
| | #ref25%23ref25)                                                  |  |
| |                                                                  |  |
| |   Visual Impa                                                    |  |
| | irment in Children Younger than Age 5 Years,                     |  |
| |                                                                X |  |
| |   Screening[                                                     |  |
| | ^[26]{.underline}^](http://www.ahrq.gov/clinic/pocketgd07/gcp1.h |  |
| | tm#ref26%23ref26)                                                |  |
| |   ------------------------                                       |  |
| | ---------------------------------------------------------------- |  |
| | -------- ------------ ----------- --------------- -------------- |  |
| |                                                                  |  |
| | ^1.^ One-time screening by ultrasonography in men aged 65 to 75  |  |
| | who have ever smoked.\                                           |  |
| | ^2.^ Adults at increased risk for coronary heart disease.\       |  |
| | ^3.^ Discuss with women at high risk for breast cancer and at    |  |
| | low risk for adverse effects of chemoprevention.\                |  |
| | ^4.^ Mammography every 1-2 years for women 40 and older.\        |  |
| | ^5.^ Refer women whose family history is associated with an      |  |
| | increased risk for deleterious mutations in BRCA1 or BRCA2 genes |  |
| | for genetic counseling and evaluation for BRCA testing.\         |  |
| | ^6.^ Structured education and behavioral counseling programs.\   |  |
| | ^7.^ Women who have been sexually active and have a cervix.\     |  |
| | ^8.^ Sexually active women 25 and younger and other asymptomatic |  |
| | women at increased risk for infection. Asymptomatic pregnant     |  |
| | women 25 and younger and others at increased risk.\              |  |
| | ^9.^ Men and women 50 and older.\                                |  |
| | ^10.^ Prescribe oral fluoride supplementation at currently       |  |
| | recommended doses to preschool children older than 6 months      |  |
| | whose primary water source is deficient in fluoride.\            |  |
| | ^11.^ In clinical practices with systems to assure accurate      |  |
| | diagnoses, effective treatment, and follow-up.\                  |  |
| | ^12.^ Adults with hypertension or hyperlipidemia.\               |  |
| | ^13.^ Adults with hyperlipidemia and other known risk factors    |  |
| | for cardiovascular and diet-related chronic disease.\            |  |
| | ^14.^ All sexually active women, including those who are         |  |
| | pregnant, at increased risk for infection (that is, if they are  |  |
| | young or have other individual or population risk factors).\     |  |
| | ^15.^ Prophylactic ocular topical medication for all newborns    |  |
| | against gonococcal ophthalmia neonatorum.\                       |  |
| | ^16.^ Pregnant women at first prenatal visit.\                   |  |
| | ^17.^ All adolescents and adults at increased risk for HIV       |  |
| | infection and all pregnant women.\                               |  |
| | ^18.^ Routine iron supplementation for asymptomatic children     |  |
| | aged 6 to 12 months who are at increased risk for iron           |  |
| | deficiency anemia.\                                              |  |
| | ^19.^ Routine screening in asymptomatic pregnant women.\         |  |
| | ^20.^ Men 35 and older and women 45 and older. Younger adults    |  |
| | with other risk factors for coronary disease. Screening for      |  |
| | lipid disorders to include measurement of total cholesterol and  |  |
| | high-density lipoprotein cholesterol.\                           |  |
| | ^21.^ Intensive counseling and behavioral interventions to       |  |
| | promote sustained weight loss for obese adults.\                 |  |
| | ^22.^ Women 65 and older and women 60 and older at increased     |  |
| | risk for osteoporotic fractures.\                                |  |
| | ^23.^ Blood typing and antibody testing at first                 |  |
| | pregnancy-related visit. Repeated antibody testing for           |  |
| | unsensitized Rh (D)-negative women at 24-28 weeks gestation      |  |
| | unless biological father is known to be Rh (D) negative.\        |  |
| | ^24.^ Persons at increased risk and all pregnant women.\         |  |
| | ^25.^ Tobacco cessation interventions for those who use tobacco. |  |
| | Augmented pregnancy-tailored counseling to pregnant women who    |  |
| | smoke.\                                                          |  |
| | ^26.^ To detect amblyopia, strabismus, and defects in visual     |  |
| | acuity.                                                          |  |
| +------------------------------------------------------------------+  |
+-----------------------------------------------------------------------+

[The Guide to Clinical Preventive Services]{.underline} 2007 in its
entirety may be downloaded at
[www.ahrq.gov/clinic/pocketgd07](http://www.ahrq.gov/clinic/pocketgd07)
. One free copy of the "Pocketbook" version of the guide may be
requested by calling 1-800-358-9295 or emailing <ahrqpubs@ahrq.hhs.gov>.

**Adult Health Maintenance Test Indications\***

*Written by U.S. Embassy London Health Unit*

(Used in conjunction with an MCU by U.S. Embassy London although routine
screening is NOT required for updating a medical clearance)

**Cervical cancer screening**

All sexually active women who have a cervix.

**STD screening (Chlamydia and gonorrhea)**

All sexually active women aged 25 and younger at increased risk.

**HIV screening**

All adolescents and adults at increased risk

**Breast cancer screening**

Screening mammography (with or without breast exam) for women aged 40
and older.

**Prostate cancer screening**

DRE and/or PSA if desired by patient and/or provider, but caveats should
be discussed with the patient. (USPSTF I = Insufficient evidence for or
against screening,

**Skin cancer screening**

Total-body skin examination for the early detection of cutaneous
melanoma, basal cell cancer, or squamous cell skin cancer if desired by
patient and/or provider. (I = Insufficient evidence to recommend for or
against screening, USPSTF)

**Colorectal cancer screening**

Men and women 50 years of age or older be screened. Options: FOBT
(annual), flexible sigmoidoscopy (5 years), combination of home FOBT and
flex sig, colonoscopy (10 years) and double-contrast barium enema (5
years).

**Lipid disorder screening**

Men aged 35 and older and women aged 45 and older who are at increased
risk for CAD. Younger adults (men aged 20 to 35 years and women aged 20
to 45 years) if other risk factors for CAD: diabetes, family history of
early (men before aged 50; women before age 60) CAD, familial
hyperlipidemia, multiple CAD risk factors (e.g. tobacco use,
hypertension). Recommended screening interval is uncertain but it is
felt that every 5 years is reasonable with shorter intervals for those
who have lipid levels close to those warranting therapy (use ATP III
guidelines to determine:
<http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf> ) and
longer intervals for low-risk people who have had low or repeatedly
normal lipid levels.

\*This list may assist in implementing the USPSTF Guidelines and should
be updated by individual posts as needed. It is not an official MED
document.