iii. The Periodic Health Examination: Age-Specific Charts 
 
The periodic health visit is an important opportunity for the delivery of  
clinical preventive services. Identification of specific preventive services  
that are appropriate for inclusion in the periodic health examination has  
been one of the principal objectives of the U.S. Preventive Services Task  
Force project. The process by which these determinations were made is  
discussed in detail in Chapter ii. This chapter explores the services that  
were evaluated by the Task Force and are recommended as part of the  
periodic health examination of the asymptomatic individual. It includes a  
series of five tables listing specific preventive services that are  
recommended for patients in different age groups. Conditions that are  
likely to benefit from early identification but that are not considered  
appropriate for routine screening are listed in Table 6. Disorders  
appearing in this table are often overlooked by clinicians due to failure to  
recognize suggestive signs or symptoms. For example, child abuse may  
not be diagnosed if physical findings suggestive of abuse are overlooked  
during routine or symptomatic examinations.<1> 
 
The Task Force judged it especially important to emphasize those  
preventive services that have been proven to be effective in properly  
conducted studies, and to tailor the content of the periodic health  
examination to the individual needs of the patient. This approach is based  
on the recognition that the limited time afforded to patient encounters may  
be most constructively used if the clinician focuses on interventions of  
proven efficacy. The clinician can then choose from among these  
effective interventions for each patient according to the likeliest causes of  
illness and injury based on that individual's age, sex, and other risk  
factors. Thus, the two most important factors to consider are the potential  
effectiveness of clinical interventions in improving clinical outcomes and  
the leading causes of mortality and morbidity. 
 
Clinical efforts directed toward promoting health and preventing disease  
are of limited value if the preventive intervention does not improve  
outcome. Thus, the major consideration in setting priorities is  
effectiveness of the intervention. Although suicide and homicide are  
important causes of death among adolescents, for example, the  
effectiveness of efforts by primary care clinicians to prevent deaths from  
intentional injuries has not been established (see Chapters 50 and 59).  
On the other hand, there are effective measures to reduce the risk of  
motor vehicle injuries, a leading cause of death in this age group. Proper  
use of safety belts has been shown to reduce the risk of injury and death  
from motor vehicle crashes by as much as 40-60%.<2-5> Alcohol  
intoxication is associated with nearly half of all fatal crashes.<6> With one  
of three deaths among young persons occurring in motor vehicle  
crashes,<7> the busy clinician seeing adolescent patients is best advised  
to direct attention to the use of safety belts and the dangers of driving  
while under the influence of alcohol, rather than to interventions of  
unproven effectiveness. For each recommendation in Tables 1-5, the  
reader is urged to refer to appropriate chapters in the text to obtain  
detailed information about the scientific rationale. 
 
It is also important to consider the leading causes of morbidity and  
mortality for patients when establishing priorities for the periodic health  
examination. For example, a clinician wishing to practice prevention  
during the few remaining minutes of an office visit with a 56-year-old  
female might consider a number of different counseling interventions that  
are effective in changing behavior, such as counseling about reducing  
dietary fat or avoiding high-risk sexual behavior. A 56-year-old female is  
considerably more likely to die from cardiac disease than from HIV or  
other sexually transmitted diseases. For women age 55-64 years in the  
U.S. during 1993, the death rate due to heart disease was 204/100,000,  
making it the second leading cause of death. HIV, on the other hand, is  
not even among the 10 leading causes of death for women of that age  
group.<7> It seems clear on the basis of mortality data alone that a few  
minutes with such a patient might be more productively spent by  
discussing dietary fat. Leading causes of death by age group are  
provided for each table. 
 
While more difficult to measure than mortality, leading causes of morbidity  
also should guide the use of preventive services. The adolescent  
population provides a clear example. Over 60% of gonococcal infections  
occur in persons under age 25.<8> The prevalence of chlamydial  
infection is highest among young women age 15-19.<9> Each year in the  
U.S., about 1 million adolescent females aged 15-19 (about 8-10% of this  
age group) and nearly 30,000 girls under age 15 become pregnant.<10>  
Thus, encounters with the adolescent population should target  
unintended pregnancy and sexually transmitted diseases as important  
causes of morbidity in this age group. Essential hypertension, neoplasms,  
and problem drinking account for a large number of office and outpatient  
department visits in older patients,<11-13> while injuries and poisonings  
account for 32% of emergency room visits among the general  
population.<14> Among elderly patients, commonly reported causes of  
chronic morbidity include visual and hearing impairments.<11> 
 
Individual risk factors are also important to consider in designing the  
periodic health examination. The leading causes of morbidity and  
mortality may differ considerably for persons in special high-risk groups  
as compared to individuals of the same age and sex in the general  
population. For example, minority children in central cities are 6 times as  
likely as non-urban non-minority children to have elevated blood lead  
levels.<15> Therefore, periodic health examinations for members of this  
high-risk population should include activities to prevent lead exposure,  
including screening. Injection drug use is also uncommon in the general  
population, but among individuals with this history, acquired  
immunodeficiency syndrome (AIDS) is the leading cause of death<16>  
and hepatitis B is an important cause of morbidity and mortality. Thus,  
essential preventive interventions in the periodic health examination of an  
injection drug user are counseling about measures to prevent  
transmission of HIV and other infectious diseases and immunization  
against hepatitis B virus. The differences in priorities among individuals in  
different age groups and risk categories and the varying effectiveness of  
some preventive services in different populations make it impossible to  
recommend a uniform periodic health examination for all persons. 
 
Many of the preventive services appearing in Tables 1-5 are  
recommended only for members of high-risk groups. These are listed  
separately in the lower half of each table and are grouped by general  
patient characteristics that broadly define high-risk populations. This  
organization will help the clinician to identify patients who might be  
eligible for one or more of the interventions listed. It is crucial, however, to  
then read the specific high-risk definition indicated by an annotated high- 
risk (HR) code after each intervention, because patients may share  
characteristics of the general high-risk grouping without actually meeting  
the individual high-risk definitions for every intervention within that group.  
For example, a 23-year-old woman whose high-risk sexual behavior is  
limited to having two recent sexual partners should be screened for  
gonorrhea and chlamydia infection, but she may not require screening for  
syphilis or a hepatitis A vaccine. To avoid providing unnecessary  
preventive services, clinicians must evaluate carefully whether patients  
who are potentially at risk meet the specific high-risk definitions for each  
potential intervention. While nonstandardized historical questions were  
not evaluated by the Task Force and therefore are not included in the  
tables, the history and physical examination can be used to identify high- 
risk individuals who would benefit from targeted interventions. Appropriate  
chapters in the text provide more detailed guidelines to help identify  
individuals at increased risk. 
 
Task Force recommendations can be compared with those of other major  
organizations and government agencies, which are listed in each chapter  
under the heading Recommendations of Other Groups. In addition, the  
Clinical Intervention section contains detailed recommendations and, in  
many cases, concise information for the clinician on: conditions to remain  
alert for, anticipatory guidance, currently recommended techniques, drug  
dosages, and other specifics for performing recommended preventive  
services. It is not the intent of the Guide to supply comprehensive  
information on how to provide these preventive services. The interested  
reader is referred to the U.S. Public Health Service's prevention  
implementation program, "Put Prevention Into Practice,"<17> and to other  
published sources on the implementation of clinical preventive  
services.<18> 
 
The preventive services examined in this report and appearing in Tables  
1-5 include only those preventive services that might be performed by  
primary care clinicians on asymptomatic persons in the context of routine  
health care (see Chapter ii). Preventive measures involving persons with  
signs or symptoms and those performed outside the clinical setting are  
not within the scope of this report or its recommendations. While the Task  
Force did not evaluate all components of the physical examination,  
several specific screening maneuvers that might be performed as part of  
the physical examination are included if they were considered. The tables  
are not intended as a complete list of all that should occur during the  
periodic health examination. Rather, these recommendations encompass  
those preventive services that have been examined by the Task Force  
and that have been shown to have satisfactory evidence of clinical  
effectiveness, based on the methodology discussed in the preceding  
chapter. 
 
At the same time, the preventive interventions listed are not exhaustive.  
The periodic health examination performed by most pediatricians, for  
example, includes a number of maneuvers that were not examined by the  
Task Force, such as screening for developmental disorders and  
anticipatory guidance; the interested reader can refer to the  
recommendations of other groups for further information on such  
topics.<19-21> Similarly, Task Force recommendations relating to  
preventive services during pregnancy should not be interpreted as  
comprehensive guidelines for prenatal care. 
 
Preventive services listed in each table are not necessarily recommended  
at every periodic visit. For example, although sigmoidoscopy is  
recommended for persons age 50 and over, it is not recommended  
annually even though periodic visits in this age group may occur once a  
year. Where a specific periodicity has been proven effective (e.g., annual  
fecal occult blood testing in persons 50 years of age and over), this  
information is included in the footnotes for each table. The Task Force  
has not attempted to design a periodicity schedule for health supervision  
visits because for many interventions, evidence of an optimal periodicity  
is lacking. In addition, periodicity for certain interventions varies with  
patient characteristics (age, gender, risk factors). 
 
Although the preventive services listed in Tables 1-5 can serve as the  
basis for designing periodic checkups devoted entirely to health  
promotion and disease prevention, they may also be performed during  
visits for other reasons (e.g., illness visits, chronic disease checkups)  
when indicated. Health maintenance needs to be considered at every  
visit. For patients with limited access to care, the illness visit may provide  
the only realistic opportunity to discuss prevention. It is recognized that  
busy clinicians may not be able to perform all recommended preventive  
services during a single clinical encounter. Indeed, it is not clear that such  
a grouping is either necessary or clinically effective. If a sparser,  
evidence-based protocol is used, health maintenance can frequently be  
done during acute visits. Patients suffering from an acute illness or injury,  
however, may not be receptive to some preventive interventions. The  
clinician must therefore use discretion in selecting appropriate preventive  
services from these tables and may wish to give special emphasis to  
those effective interventions aimed at the leading causes of illness and  
disability in the age group. Recommended preventive services that cannot  
be performed by the clinician at the current visit should be scheduled for a  
later health visit. 
 
Immunizations appearing in Tables 1-5 are those recommended on a  
routine basis and do not apply to persons with special exposures to  
infected individuals. The reader is referred to Chapter 67 for detailed  
guidelines on immunizations in such circumstances. 
 
Tables 1-5 do not include interventions for which the Task Force found  
insufficient evidence on which to base recommendations for or against  
inclusion in the periodic health examination (i.e., C recommendations).  
The Task Force recognizes that there may be other grounds on which to  
base a recommendation for or against an intervention when scientific  
evidence is not available, including patient preference, costs associated  
with the procedure, the likelihood of benefit or harms from the procedure,  
and the burden of suffering from the condition. Consideration of these  
other grounds can guide the clinician in making decisions about the  
appropriate use of these interventions. The reader is referred to Chapter ii  
for detailed discussion of the development of C recommendations. For  
many important causes of morbidity and mortality, evidence of effective  
preventive interventions is lacking. There is a great need for well- 
controlled, randomized studies with adequate sample sizes to evaluate  
the effectiveness of preventive interventions for many conditions. Such  
topics merit attention in the planning of future research agendas. 
 
Table 1. Birth to 10 Years 

Interventions Considered and Recommended for the Periodic Health Examination

Leading Causes of Death 
	Conditions originating in perinatal period 
	Congenital anomalies 
	Sudden infant death syndrome (SIDS) 
	Unintentional injuries (non- motor vehicle) 
	Motor vehicle injuries 
 
Interventions for the General Population 
 
SCREENING 
Height and weight [Ch 21] 
Blood pressure [Ch 3 ] 
Vision screen (age 3-4 yr) [Ch 33] 
Hemoglobinopathy screen (birth)1 [Ch 43 ] 
Phenylalanine level (birth)2 [Ch 44 ] 
T4 and/or TSH (birth)3 [Ch 45] 
 
COUNSELING 
Injury Prevention [Ch 57,58 ] 
	Child safety car seats (age <5 yr) 
	Lap-shoulder belts (age 5 yr) 
	Bicycle helmet, avoid bicycling near traffic 
	Smoke detector, flame retardant sleepwear 
	Hot water heater temperature <120-130F 
	Window/stair guards, pool fence 
	Safe storage of drugs, toxic substances, firearms, & matches 
	Syrup of ipecac, poison control phone number 
	CPR training for parents/caretakers 
 
Diet and Exercise 
Breast-feeding, iron-enriched formula and foods (infants & toddlers)  
[Ch 22,56 ] 
Limit fat & cholesterol, maintain caloric balance, emphasize grains,  
fruits, vegetables (age 2 yr) [Ch 56 ] 
Regular physical activity* [Ch 55 ] 
Substance Use [Ch 54 ] 
	Effects of passive smoking* 
	Anti-tobacco message* 
Dental Health [Ch 61 ] 
	Regular visits to dental care provider* 
	Floss, brush with fluoride toothpaste daily* 
	Advice about baby bottle tooth decay* 
 
IMMUNIZATIONS [Ch 65 ] 
	Diphtheria-tetanus-pertussis (DTP)<4> 
	Oral poliovirus (OPV)<5> 
	Measles-mumps-rubella (MMR)<6> 
	H. influenzae type b (Hib) conjugate<7> 
	Hepatitis B<8> 
	Varicella<9> 
 
CHEMOPROPHYLAXIS 
Ocular prophylaxis (birth) [Ch 27 ] 
 
Interventions for High-Risk Populations 
 
POPULATION--POTENTIAL INTERVENTIONS (See detailed high-risk definitions) 

Preterm or low birth weight--Hemoglobin/hematocrit (HR1) 

Infants of mothers at risk for HIV --HIV testing (HR2) 

Low income; immigrants--Hemoglobin/hematocrit (HR1); PPD (HR3)  

TB contacts--PPD (HR3) 

Native American/Alaska Native--Hemoglobin/hematocrit (HR1); PPD (HR3); hepatitis  
A vaccine (HR4); pneumococcal vaccine (HR5) 

Travelers to developing countries--Hepatitis A vaccine (HR4) 

Residents of long-term care facilities--PPD (HR3); hepatitis A vaccine (HR4); influenza 	 
vaccine (HR6) 

Certain chronic medical conditions--PPD (HR3); pneumococcal vaccine (HR5); 
influenza vaccine (HR6) 

Increased individual or community lead exposure--Blood lead level (HR7) 

Inadequate water fluoridation--Daily fluoride supplement (HR8) 

Family h/o skin cancer; nevi;fair skin, eyes, hair--Avoid excess/midday sun, use  
protective clothing* (HR9) 
 
HR1 = Infants age 6-12 mo who are: living in poverty, black, Native  
American or Alaska Native, immigrants from developing countries,  
preterm or low birth weight infants, or infants whose principal dietary  
intake is unfortified cow's milk (see Ch. 22). 
HR2 = Infants born to high-risk mothers whose HIV status is unknown.  
Women at high risk  include: past or present injection drug use;  
persons who exchange sex for money or drugs, and their sex partners;  
injection drug-using, bisexual, or HIV-positive sex partners currently or  
in past; persons seeking treatment for STDs; blood transfusion during  
1978-1985 (see Ch. 28). 
HR3 = Persons infected with HIV, close contacts of persons with  
known or suspected TB, persons with medical risk factors associated  
with TB, immigrants from countries with high TB prevalence, medically  
underserved low-income populations (including homeless), residents  
of long-term care facilities (see Ch. 25). See Ch. 25 for indications for  
BCG vaccine. 
HR4 = Persons 2 yr living in or traveling to areas where the disease is  
endemic and where periodic outbreaks occur (e.g., countries with high  
or intermediate endemicity; certain Alaska Native, Pacific Island,  
Native American, and religious communities). Consider for  
institutionalized children aged 2 yr. Clinicians should also consider  
local epidemiology (see Ch. 65-67). 
HR5 = Immunocompetent persons 2 yr with certain medical  
conditions, including chronic cardiac or pulmonary disease, diabetes  
mellitus, and anatomic asplenia. Immunocompetent persons 2 yr  
living in high-risk environments or social settings (e.g., certain Native  
American and Alaska Native populations) (see Ch. 66). 
HR6 = Annual vaccination of children 6 mo who are residents of  
chronic care facilities or who have chronic cardiopulmonary disorders,  
metabolic diseases (including diabetes mellitus), hemoglobinopathies,  
immunosuppression, or renal dysfunction (see Ch. 66). See Ch. 66 for  
indications for amantadine/rimantadine prophylaxis. 
HR7 = Children about age 12 mo who: 1) live in communities in which  
the prevalence of lead levels requiring individual intervention,  
including residential lead hazard control or chelation, is high or  
undefined; 2) live in or frequently visit a home built before 1950 with  
dilapidated paint or with recent or ongoing renovation or remodeling;  
3) have close contact with a person who has an elevated lead level; 4)  
live near lead industry or heavy traffic; 5) live with someone whose job  
or hobby involves lead exposure; 6) use lead-based pottery; or 7) take  
traditional ethnic remedies that contain lead (see Ch. 23). 
HR8 = Children living in areas with inadequate water fluoridation (<0.6  
ppm) (see Ch. 61). 
HR9 = Persons with a family history of skin cancer, a large number of  
moles, atypical moles, poor tanning ability, or light skin, hair, and eye  
color (see Ch. 12). 
 
 
 Table 2. Ages 11-24 Years 
 
Interventions Considered and Recommended for the Periodic Health Examination

Leading Causes of Death 
	Motor vehicle/other unintentional injuries  
	Homicide 
	Suicide 
	Malignant neoplasms 
	Heart diseases 
 
Interventions for the General Population

SCREENING 
Height & weight [Ch 21] 
Blood pressure1 [Ch 3]  
Papanicolaou (Pap) test2 (females) [Ch 9] 
Chlamydia screen3 (females <20 yr) [Ch 29] 
Rubella serology or vaccination hx4 (females >12 yr) [Ch 32] 
Assess for problem drinking [Ch 52] 
 
COUNSELING 
Injury Prevention [Ch 57,58] 
	Lap/shoulder belts 
	Bicycle/motorcycle/ATV helmets* 
	Smoke detector* 
Safe storage/removal of firearms* [Ch 50,59] 
	Substance Use 
Avoid tobacco use [Ch 54] 
Avoid underage drinking & illicit drug use* [Ch 52,53] 
Avoid alcohol/drug use while driving, swimming, boating,etc.* [Ch  
57,58] 
Sexual Behavior [Ch 62,63] 
	STD prevention: abstinence;* avoid high-risk behavior;*  
	condoms/female barrier with spermicide* 
	Unintended pregnancy: contraception 
 
Diet and Exercise 
Limit fat & cholesterol; maintain caloric balance; emphasize grains,  
fruits, vegetables [Ch 56] 
Adequate calcium intake (females) [Ch 56] 
Regular physical activity* [Ch 55] 
Dental Health [Ch 61] 
	Regular visits to dental care provider* 
	Floss, brush with fluoride toothpaste daily* 
 
IMMUNIZATIONS [Ch 65,66] 
	Tetanus-diphtheria (Td) boosters (11-16 yr)  
	Hepatitis B5 
	MMR (11-12 yr)<6> 
	Varicella (11-12 yr)<7> 
	Rubella<4> (females >12 yr) [Ch 32] 
 
CHEMOPROPHYLAXIS 
Multivitamin with folic acid (females planning/capable of pregnancy)  
[Ch 42] 
 
Interventions for High-Risk Populations 
 
POPULATION -- POTENTIAL INTERVENTIONS (See detailed high-risk definitions) 
 
High-risk sexual behavior-- RPR/VDRL (HR1); screen for gonorrhea (female) (HR2), 
	HIV (HR3), chlamydia (female) (HR4); hepatitis A vaccine (HR5) 
 
Injection or street drug use -- RPR/VDRL (HR1); HIV screen (HR3); hepatitis A vaccine 
	(HR5); PPD (HR6); advice to reduce infection risk (HR7)  
 
TB contacts; immigrants; low income -- PPD (HR6) 
 
Native Americans/Alaska Natives -- Hepatitis A vaccine (HR5); PPD (HR6); 
	pneumococcal vaccine (HR8) 
 
Travelers to developing countries-- Hepatitis A vaccine (HR5) 

Certain chronic medical conditions--PPD (HR6); pneumococcal vaccine (HR8); 
	influenza vaccine (HR9) 
 
Settings where adolescents and young adults congregate -- Second MMR (HR10) 

Susceptible to varicella, measles, mumps-- Varicella vaccine (HR11); MMR (HR12) 

Blood transfusion between 1978-1985-- HIV screen (HR3) 

Institutionalized persons; health care/lab workers -- Hepatitis A vaccine (HR5); PPD 
	(HR6); influenza vaccine (HR9) 
 
Family h/o skin cancer; nevi; fair skin, eyes, hair -- Avoid excess/midday sun, use 
	protective clothing* (HR13) 

Prior pregnancy with neural tube defect -- Folic acid 4.0 mg (HR14) 

Inadequate water fluoridation -- Daily fluoride supplement (HR15)

HR1 = Persons who exchange sex for money or drugs, and their sex partners; persons with other STDs (including HIV); and sexual contacts of persons with active syphilis. Clinicians should also consider local epidemiology (see Ch. 26).
HR2 = Females who have: two or more sex partners in the last year; a sex partner with multiple sexual contacts; exchanged sex for money or drugs; or a history of repeated episodes of gonorrhea. Clinicians should also consider local epidemiology (see Ch. 27).
HR3 = Males who had sex with males after 1975; past or present injection drug use; persons who exchange sex for money or drugs, and their sex partners; injection drug-using, bisexual, or HIV-positive sex partner currently or in the past; blood transfusion during 1978-1985; persons seeking treatment for STDs. Clinicians should also consider local epidemiology (see Ch. 28).
HR4 = Sexually active females with multiple risk factors including: history of prior STD; new or multiple sex partners; age under 25; nonuse or inconsistent use of barrier contraceptives; cervical ectopy. Clinicians should consider local epidemiology of the disease in identifying other high-risk groups (see Ch. 29).
HR5 = Persons living in, traveling to, or working in areas where the disease is endemic and where periodic outbreaks occur (e.g., countries with high or intermediate endemicity; certain Alaska Native, Pacific Island, Native American, and religious communities); men who have sex with men; injection or street drug users. Vaccine may be considered for institutionalized persons and workers in these institutions, military personnel, and day-care, hospital, and laboratory workers. Clinicians should also consider local epidemiology (see Ch. 66, 67).
HR6 = HIV positive, close contacts of persons with known or suspected TB, health care workers, persons with medical risk factors associated with TB, immigrants from countries with high TB prevalence, medically underserved low-income populations (including homeless), alcoholics, injection drug users, and residents of long-term care facilities (see Ch. 25). See Ch. 25 for indications for BCG vaccine.
HR7 = Persons who continue to inject drugs (see Ch. 53).
HR8 = Immunocompetent persons with certain medical conditions, including chronic cardiac or pulmonary disease, diabetes mellitus, and anatomic asplenia. Immunocompetent persons who live in high-risk environments or social settings (e.g., certain Native American and Alaska Native populations) (see Ch. 66).
HR9 = Annual vaccination of: residents of chronic care facilities; persons with chronic cardiopulmonary disorders, metabolic diseases (including diabetes mellitus), hemoglobinopathies, immunosuppression, or renal dysfunction; and health care providers for high-risk patients (see Ch. 66). See Ch. 66 for indications for amantadine/rimantadine prophylaxis.
HR10 = Adolescents and young adults in settings where such individuals congregate (e.g., high schools and colleges), if they have not previously received a second dose (see Ch. 65, 66).
HR11 = Healthy persons aged <13 yr without a history of chickenpox or previous immunization. Consider serologic testing for presumed susceptible persons aged <13 yr (see Ch. 65, 66).
HR12 = Persons born after 1956 who lack evidence of immunity to measles or mumps (e.g., documented receipt of live vaccine on or after the first birthday, laboratory evidence of immunity, or a history of physician-diagnosed measles or mumps) (see Ch. 65, 66).
HR13 = Persons with a family or personal history of skin cancer, a large number of moles, atypical moles, poor tanning ability, or light skin, hair, and eye color (see Ch. 12).
HR14 = Women with prior pregnancy affected by neural tube defect who are planning pregnancy (see Ch. 42).
HR15 = Persons aged <17 yr living in areas with inadequate water fluoridation (<0.6 ppm) (see Ch. 61).

Table 3. Ages 25-64 Years

Interventions Considered and Recommended for the Periodic Health Examination

Leading Causes of Death
	Malignant neoplasms  
	Heart diseases
	Motor vehicle and other unintentional injuries 
	Human immunodeficiency virus (HIV) infection
	Suicide and homicide
 
Interventions for the General Population

SCREENING
Blood pressure [Ch 3]
Height and weight [Ch 21]
Total blood cholesterol (men ages 35-65, women ages 45-65) [Ch 2]
Papanicolaou (Pap) test (women)<1> [Ch 9]
Fecal occult blood test<2> and/or sigmoidoscopy (50 yr) [Ch 8]
Mammogram  clinical breast exam<3> (women 50-69 yr) [Ch 7]
Assess for problem drinking [Ch 52]
Rubella serology or vaccination hx<4> (women of childbearing age) [Ch 32]

COUNSELING
Substance Use
Tobacco cessation [Ch 54]
Avoid alcohol/drug use while driving, swimming, boating, etc.* [Ch 57,58]

Diet and Exercise
Limit fat & cholesterol; maintain caloric balance; emphasize grains, fruits, vegetables 
[Ch 56]
Adequate calcium intake (women) [Ch 56]
Regular physical activity* [Ch 55]
Injury Prevention [Ch 57,58]
	Lap/shoulder belts
	Motorcycle/bicycle/ATV helmets*
	Smoke detector*
Safe storage/removal of firearms* [Ch 50,59]
Sexual Behavior [Ch 62,63 ]
STD prevention: avoid high-risk behavior;* condoms/female barrier with spermicide*
	Unintended pregnancy: contraception 
Dental Health [Ch 61]
	Regular visits to dental care provider*
	Floss, brush with fluoride toothpaste daily*

IMMUNIZATIONS [Ch 32,66 ]
	Tetanus-diphtheria (Td) boosters
	Rubella<4> (women of childbearing age) 

CHEMOPROPHYLAXIS
Multivitamin with folic acid (women planning or capable of pregnancy) [Ch 42]
Discuss hormone prophylaxis (peri- and postmenopausal women) [Ch 68]

INTERVENTIONS FOR HIGH-RISK POPULATIONS

POPULATION -- POTENTIAL INTERVENTIONS (See detailed high-risk definitions)

High-risk sexual behavior -- RPR/VDRL (HR1); screen for gonorrhea (female) (HR2), 
	HIV (HR3), chlamydia (female) (HR4); hepatitis B vaccine (HR5); hepatitis A 
	vaccine (HR6)

Injection or street drug use -- RPR/VDRL (HR1); HIV screen (HR3); hepatitis B vaccine 
	(HR5); hepatitis A vaccine (HR6); PPD (HR7); advice to reduce infection risk 
	(HR8)

Low income; TB contacts; immigrants; alcoholics -- PPD (HR7)

Native Americans/Alaska Natives -- Hepatitis A vaccine (HR6); PPD (HR7); 
	pneumococcal vaccine (HR9)

Travelers to developing countries -- Hepatitis B vaccine (HR5); hepatitis A vaccine 
	(HR6)

Certain chronic medical conditions-- PPD (HR7); pneumococcal vaccine (HR9); 
	influenza vaccine (HR10)

Blood product recipients -- HIV screen (HR3); hepatitis B vaccine (HR5)

Susceptible to measles, mumps, or varicella -- MMR (HR11); varicella vaccine (HR12)

Institutionalized persons -- Hepatitis A vaccine (HR6); PPD (HR7); pneumococcal 
	vaccine (HR9); influenza vaccine (HR10)

Health care/lab workers -- Hepatitis B vaccine (HR5); hepatitis A vaccine (HR6); PPD 
	(HR7); influenza vaccine (HR10)

Family h/o skin cancer; fair skin, eyes, hair -- Avoid excess/midday sun, use protective 
	clothing* (HR13)

Previous pregnancy with neural tube defect -- Folic acid 4.0 mg (HR14)

HR1 = Persons who exchange sex for money or drugs, and their sex 
partners; persons with other STDs (including HIV); and sexual contacts of 
persons with active syphilis. Clinicians should also consider local 
epidemiology (see Ch. 26).
HR2 = Women who exchange sex for money or drugs, or who have had 
repeated episodes of gonorrhea. Clinicians should also consider local 
epidemiology (see Ch. 27).
HR3 = Men who had sex with men after 1975; past or present injection 
drug use; persons who exchange sex for money or drugs, and their sex 
partners; injection drug-using, bisexual, or HIV-positive sex partner 
currently or in the past; blood transfusion during 1978-1985; persons 
seeking treatment for STDs. Clinicians should also consider local 
epidemiology (see Ch. 28).
HR4 = Sexually active women with multiple risk factors including: history 
of STD; new or multiple sex partners; nonuse or inconsistent use of 
barrier contraceptives; cervical ectopy. Clinicians should also consider 
local epidemiology (see Ch. 29).
HR5 = Blood product recipients (including hemodialysis patients), 
persons with frequent occupational exposure to blood or blood products, 
men who have sex with men, injection drug users and their sex partners, 
persons with multiple recent sex partners, persons with other STDs 
(including HIV), travelers to countries with endemic hepatitis B (see Ch. 
66).
HR6 = Persons living in, traveling to, or working in areas where the 
disease is endemic and where periodic outbreaks occur (e.g., countries 
with high or intermediate endemicity; certain Alaska Native, Pacific Island, 
Native American, and religious communities); men who have sex with 
men; injection or street drug users. Consider for institutionalized persons 
and workers in these institutions, military personnel, and day-care, 
hospital, and laboratory workers. Clinicians should also consider local 
epidemiology (see Ch. 66, 67).
HR7 = HIV positive, close contacts of persons with known or suspected 
TB, health care workers, persons with medical risk factors associated with 
TB, immigrants from countries with high TB prevalence, medically 
underserved low-income populations (including homeless), alcoholics, 
injection drug users, and residents of long-term care facilities (see Ch. 
25). See Ch. 25 for indications for BCG vaccine.
HR8 = Persons who continue to inject drugs (see Ch. 53).
HR9 = Immunocompetent institutionalized persons aged 50 yr and 
immunocompetent persons with certain medical conditions, including 
chronic cardiac or pulmonary disease, diabetes
mellitus, and anatomic asplenia. Immunocompetent persons who live in 
high-risk environments or social settings (e.g., certain Native American 
and Alaska Native populations) (see Ch. 66).
HR10 = Annual vaccination of residents of chronic care facilities; persons 
with chronic cardiopulmonary disorders, metabolic diseases (including 
diabetes mellitus), hemoglobinopathies, immunosuppression, or renal 
dysfunction; and health care providers for high-risk patients (Ch. 66). See 
Ch. 66 for indications for amantadine/rimantadine prophylaxis.
HR11 = Persons born after 1956 who lack evidence of immunity to 
measles or mumps (e.g., documented receipt of live vaccine on or after 
the first birthday, laboratory evidence of immunity, or a history of 
physician-diagnosed measles or mumps) (see Ch. 66).
HR12 = Healthy adults without a history of chickenpox or previous 
immunization. Consider serologic testing for presumed susceptible adults 
(see Ch. 65, 66).
HR13 = Persons with a family or personal history of skin cancer, a large 
number of moles, atypical moles, poor tanning ability, or light skin, hair, 
and eye color (see Ch. 12).
HR14 = Women with previous pregnancy affected by neural tube defect 
who are planning pregnancy (see Ch. 42).

Table 4. Age 65 and Older

Interventions Considered and Recommended for the Periodic Health Examination

Leading Causes of Death
	Heart diseases
	Malignant neoplasms (lung, colorectal, breast) 
	Cerebrovascular disease
	Chronic obstructive pulmonary disease
	Pneumonia and influenza

 Interventions for the General Population

SCREENING
Blood pressure [Ch 3]
Height and weight [Ch 21]
Fecal occult blood test<1> and/or sigmoidoscopy [Ch 8]
Mammogram  clinical breast exam<2> (women 69 yr) [Ch 7]
Papanicolaou (Pap) test (women)<3> [Ch 9]
Vision screening [Ch 33]
Assess for hearing impairment [Ch 35]
Assess for problem drinking [Ch 52]

COUNSELING
Substance Use
Tobacco cessation [Ch 54]
Avoid alcohol/drug use while driving, swimming, boating, etc.* [Ch 57,58]

Diet and Exercise
Limit fat & cholesterol; maintain caloric balance; emphasize grains, fruits, vegetables 
[Ch 56]
Adequate calcium intake (women) [Ch 56]
Regular physical activity* [Ch 55,58]

Injury Prevention [Ch 57,58]
	Lap/shoulder belts 
	Motorcycle and bicycle helmets*
	Fall prevention*
	Safe storage/removal of firearms* [Ch 50,59]
	Smoke detector*
	Set hot water heater to <120-130 deg.F*
	CPR training for household members

Dental Health [Ch 61]
	Regular visits to dental care provider*
	Floss, brush with fluoride toothpaste daily*

Sexual Behavior
	STD prevention: avoid high-risk sexual behavior;* use condoms* [Ch 62]

IMMUNIZATIONS [Ch 66]
Pneumococcal vaccine
Influenza<1>
Tetanus-diphtheria (Td) boosters

CHEMOPROPHYLAXIS
Discuss hormone prophylaxis (women) [Ch 68]

INTERVENTIONS FOR HIGH-RISK POPULATIONS

POPULATION -- POTENTIAL INTERVENTIONS (See detailed high-risk definitions)

Institutionalized persons -- PPD (HR1); hepatitis A vaccine (HR2); 
	amantadine/rimantadine (HR4)

Chronic medical conditions; TB contacts; low income; immigrants; alcoholics -- PPD 
(HR1)

Persons 75 yr; or  70 yr with risk factors for falls -- Fall prevention intervention (HR5)

Cardiovascular disease risk factors -- Consider cholesterol screening (HR6)

Family h/o skin cancer; nevi; fair skin, eyes, hair -- Avoid excess/midday sun, use 
	protective clothing* (HR7)

Native Americans/Alaska Natives -- Hepatitis A vaccine (HR2); hepatitis B vaccine 
	(HR8)

Travelers to developing countries -- HIV screen (HR3); hepatitis B vaccine (HR8)

Blood product recipients -- Hepatitis A vaccine (HR2); HIV screen (HR3); hepatitis B 
	vaccine (HR8); RPR/VDRL (HR9)

High-risk sexual behavior -- PPD (HR1); hepatitis A vaccine (HR2); HIV screen (HR3); 
	hepatitis B vaccine (HR8); RPR/VDRL (HR9); advice to reduce infection risk 
	(HR10)

Injection or street drug use -- PPD (HR1); hepatitis A vaccine (HR2); 
	amantadine/rimantadine (HR4); hepatitis B vaccine (HR8)

Health care/lab workers -- PPD (HR1); hepatitis A vaccine (HR2); 
	amantadine/rimantadine (HR4); hepatitis B vaccine (HR8)

Persons susceptible to varicella -- Varicella vaccine (HR11)

HR1 = HIV positive, close contacts of persons with known or suspected 
TB, health care workers, persons with medical risk factors associated with 
TB, immigrants from countries with high TB prevalence, medically 
underserved low-income populations (including homeless), alcoholics, 
injection drug users, and residents of long-term care facilities (see Ch. 
25). See Ch. 25 for indications for BCG vaccine.
HR2 = Persons living in, traveling to, or working in areas where the 
disease is endemic and where periodic outbreaks occur (e.g., countries 
with high or intermediate endemicity; certain Alaska Native, Pacific Island, 
Native American, and religious communities); men who have sex with 
men; injection or street drug users. Consider for institutionalized persons 
and workers in these institutions, and day-care, hospital, and laboratory 
workers. Clinicians should also consider local epidemiology (see Ch. 66, 
67).
HR3 = Men who had sex with men after 1975; past or present injection 
drug use; persons who exchange sex for money or drugs, and their sex 
partners; injection drug-using, bisexual, or HIV-positive sex partner 
currently or in the past; blood transfusion during 1978-1985; persons 
seeking treatment for STDs. Clinicians should also consider local 
epidemiology (see Ch. 28).
HR4 = Consider for persons who have not received influenza vaccine or 
are vaccinated late; when the vaccine may be ineffective due to major 
antigenic changes in the virus; for unvaccinated persons who provide 
home care for high-risk persons; to supplement protection provided by 
vaccine in persons who are expected to have a poor antibody response; 
and for high-risk persons in whom the vaccine is contraindicated (see Ch. 
66).
HR5 = Persons aged 75 years and older; or aged 70-74 with one or more 
additional risk factors including: use of certain psychoactive and cardiac 
medications (e.g., benzodiazepines, antihypertensives); use of 4 
prescription medications; impaired cognition, strength, balance, or gait. 
Intensive individualized home-based multifactorial fall prevention 
intervention is recommended in settings where adequate resources are 
available to deliver such services (see Ch. 58).
HR6 = Although evidence is insufficient to recommend routine screening 
in elderly persons, clinicians should consider cholesterol screening on a 
case-by-case basis for persons ages 65-75 with additional risk factors 
(e.g., smoking, diabetes, or hypertension) (see Ch. 2).
HR7 = Persons with a family or personal history of skin cancer, a large 
number of moles, atypical moles, poor tanning ability, or light skin, hair, 
and eye color (see Ch. 12).
HR8 = Blood product recipients (including hemodialysis patients), 
persons with frequent occupational exposure to blood or blood products, 
men who have sex with men, injection drug users and their sex partners, 
persons with multiple recent sex partners, persons with other STDs 
(including HIV), travelers to countries with endemic hepatitis B (see Ch. 
66).
HR9 = Persons who exchange sex for money or drugs and their sex 
partners; persons with other STDs (including HIV); and sexual contacts of 
persons with active syphilis. Clinicians should also consider local 
epidemiology (see Ch. 26).
HR10 = Persons who continue to inject drugs (see Ch. 53).
HR11 = Healthy adults without a history of chickenpox or previous 
immunization. Consider serologic testing for presumed susceptible adults 
(see Ch. 65, 66).

Table 5. Pregnant Women

Interventions Considered and Recommended for the Periodic Health Examination

INTERVENTIONS FOR THE GENERAL POPULATION 

SCREENING
First visit
	Blood pressure [Ch 3,37]
	Hemoglobin/hematocrit [Ch 22]
	Hepatitis B surface antigen (HBsAg) [Ch 24]
	RPR/VDRL [Ch 26]
	Chlamydia screen (<25 yr) [Ch 29]
	Rubella serology or vaccination history [Ch 32]
	D(Rh) typing, antibody screen [Ch 38]
	Offer CVS (<13 wk)<1> or amniocentesis (15-18 wk)1 (age 35 yr) [Ch 41]
	Offer hemoglobinopathy screening [Ch 43]
	Assess for problem or risk drinking [Ch 52]
	Offer HIV screening<2> [Ch 28]

Follow-up visits
	Blood pressure [Ch 3,37]
	Urine culture (12-16 wk) [Ch 31]
	Offer amniocentesis (15-18 wk)1 (age 35 yr) [Ch 41]
	Offer multiple marker testing1 (15-18 wk) [Ch 41]
	Offer serum a-fetoprotein1 (16-18 wk) [Ch 42]

COUNSELING
Tobacco cessation; effects of passive smoking [Ch 54]
Alcohol/other drug use [Ch 52,53]
Nutrition, including adequate calcium intake [Ch 56]
Encourage breastfeeding [Ch 22,56]
Lap/shoulder belts [Ch 57]
Infant safety car seats [Ch 57]
STD prevention: avoid high-risk sexual behavior;* use condoms* [Ch 62]

CHEMOPROPHYLAXIS
Multivitamin with folic acid<3> [Ch 42]

INTERVENTIONS FOR HIGH-RISK POPULATIONS

POPULATION -- POTENTIAL INTERVENTIONS (See detailed high-risk definitions)

High-risk sexual behavior -- Screen for chlamydia (1st visit) (HR1), gonorrhea (1st visit) 
	(HR2), HIV (1st visit) (HR3); HBsAg (3rd trimester) (HR4); RPR/VDRL (3rd 
	trimester) (HR5)

Blood transfusion 1978-1985 -- HIV screen (1st visit) (HR3)

Injection drug use -- HIV screen (HR3); HBsAg (3rd trimester) (HR4); advice to reduce 
infection risk (HR6)

Unsensitized D-negative women -- D(Rh) antibody testing (24-28 wk) (HR7)

Risk factors for Down syndrome -- Offer CVS1 (1st trimester), amniocentesis1 (15-18 
	wk) (HR8)

Prior pregnancy with neural tube defect -- Folic acid 4.0 mg,3 offer amniocentesis1 (15-
	18 wk) (HR9)

HR1 = Women with history of STD or new or multiple sex partners. 
Clinicians should also consider local epidemiology. Chlamydia screen 
should be repeated in 3rd trimester if at continued risk (see Ch. 29).
HR2 = Women under age 25 with two or more sex partners in the last 
year, or whose sex partner has multiple sexual contacts; women who 
exchange sex for money or drugs; and women with a history of repeated 
episodes of gonorrhea. Clinicians should also consider local 
epidemiology. Gonorrhea screen should be repeated in the 3rd trimester 
if at continued risk (see Ch. 27).
HR3 = In areas where universal screening is not performed due to low 
prevalence of HIV infection, pregnant women with the following individual 
risk factors should be screened: past or present injection drug use; 
women who exchange sex for money or drugs; injection drug-using, 
bisexual, or HIV-positive sex partner currently or in the past; blood 
transfusion during 1978-1985; persons seeking treatment for STDs (see 
Ch. 28).
HR4 = Women who are initially HBsAg-negative who are at high risk due 
to injection drug use, suspected exposure to hepatitis B during 
pregnancy, multiple sex partners (see Ch. 24).
HR5 = Women who exchange sex for money or drugs, women with other 
STDs (including HIV), and sexual contacts of persons with active syphilis. 
Clinicians should also consider local epidemiology (see Ch. 26).
HR6 = Women who continue to inject drugs (see Ch. 53).
HR7 = Unsensitized D-negative women (see Ch. 38).
HR8 = Prior pregnancy affected by Down syndrome, advanced maternal 
age (35 yr), known carriage of chromosome rearrangement (see Ch. 41).
HR9 = Women with previous pregnancy affected by neural tube defect 
(see Ch. 42).

Table 6. Conditions for Which Clinicians Should Remain Alert

Condition			Population				      Chapter

Symptoms of peripheral 	Older persons, smokers, diabetic 	5
arterial disease		persons 	

Skin lesions with 		General population, particularly 		12
malignant features		those with established risk factors 

Symptoms and signs of oral 	Persons who use tobacco, older 	16
cancer and premalignancy		persons who drink alcohol regularly

Subtle or nonspecific 	Older persons, postpartum 		20
symptoms and signs of 	women, persons with Down
thyroid dysfunction		syndrome

Signs of ocular misalignment 	Infants and children			33

Symptoms and signs of 	Infants and young children (<3 yr)	35
hearing impairment

Large spinal curvatures	Adolescents					47

Changes in functional 	Older persons				48
performance

Depressive symptoms	Adolescents, young adults, 		49
				persons at increased risk for 
				depression 

Evidence of suicidal ideation 	Persons with established risk 	50
					actors for suicide 

Various presentations of family 	General population			51
violence

Symptoms and signs of drug 	General population			53
abuse

Obvious signs of untreated	General population			61
tooth decay or mottling, 
inflamed or cyanotic gingiva, 
loose teeth, and severe halitosis

Evidence of early childhood 	Children				61
caries, mismatching of upper 
and lower dental arches, dental 
crowding or malalignment, 
premature loss of primary 
posterior teeth (baby molars) 
and obvious mouth breathing 

The draft update of this chapter was prepared for the U.S. Preventive  
Services Task Force by Ann O'Malley, MD, MPH, and Carolyn  
DiGuiseppi, MD, MPH. 
 
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