Paratus · DD FORM 2766 — Adult Preventive and Chronic Care Flowsheet

Adult Preventive and Chronic Care Flowsheet

Patient identification

1. Allergies

2. Chronic illnesses · 3. Medications

4. Hospitalizations / Surgeries

5. Counseling

Advanced directives

6. Family history

7. Screening exams

8. Occupational history / risk

9. Immunizations

10. Readiness

11. Pre / post deployment history

Continuation sheet

Records maintained at — complete the demographic block. (Use this space for mechanical imprint.)

Patient's name — Last

First

M.I.

Sex

Relationship to sponsor

Status

Rank/Grade

Sponsor's name (Last, First, Middle Initial)

Dept/Service

Organization

SSN/ID number

Date of birth

Records maintained at

List medication allergies and other allergies (or enter NKDA).

a. Medication allergies

b. Other allergies

Active chronic/significant problem list and long-term medications.

2. Chronic illnesses

3. Medications

List hospitalizations and surgical procedures with dates.

Record counseling by topic code — F Fitness · D Dental · I Injury Prevention · N Nutrition/Folate · C Cancer Prevention · S Safe Sex · FP Family Planning · Rx Present Medications · MH Mental Health/Stress/Suicide/Occupational Stress · H Hormone/Calcium Replacement · To Tobacco · A Alcohol/Substance Abuse · T Travel · O Occupational Exposure (hearing threshold changes / cumulative trauma disorder).

Date	Age	Topic(s) counseled — enter code(s)

Date filed

Relation codes — M = Mother · F = Father · S = Sibling · MGM = Maternal Grandmother · MGF = Maternal Grandfather · PGM = Paternal Grandmother · PGF = Paternal Grandfather.

a. Cancer (specify)

b. Cardiovascular disease (specify)

c. Diabetes (specify)

d. Mental illness / chemical dependency (specify)

Result codes — * = Actual Result · ** = Tricare Benefit · N = Normal · X = Abnormal · E = Done Elsewhere · R = Refused · NA = Not Indicated · ● = Next Due.

a. Test	b. Frequency	c. Year / d. Age	e. Date & result	Date & result	Date & result	Date & result
(1) Clinical disease prev eval/PHA (hear)	Annual
*(2) Weight	Annual for active duty
*(3) Height	Annual for active duty
*(4) Blood pressure	Once q 2 yrs for BP < 130/85, annual if greater
(5) Cholesterol*	q 5 yrs for age ≥18, q yr if prev abn
(6) Hearing	Clinician's discretion
(7) Skin exam (cancer)	Annual if at risk
(8) Oral/dental**	Annual
(9) Eye/vision**	Routine acuity with periodic assessment; diabetes annually; glaucoma check: Blacks q 3-5 yrs age 20-39, all q 2-4 yrs age 40-64
(10) Breast exam	Annual: ≥40 yrs
(11) Mammogram**	Baseline @40, q 2 yrs 40-50, annually >50
(12) Pap **(Digital rectal exam)	Baseline: age 18 or onset of sexual activity; after 3 NL annual exams, perform q 1-3 years
(13) Fecal occult blood	Annual: ≥50 yrs
(14) Sigmoid	Every 3-5 yrs: ≥50 yrs
(15) Colonoscopy**	High risk q 5 yrs: ≥40 yrs
(16) Testicular**	High risk annual 13-39 yrs
(17) Prostate (Digital rectal exam)	With P.E. ≥40 yrs (presently recommended annually)
(18) Rubella screen (females)	Once between ages 12-18 yrs (unless prev vaccinated)
(19) Occupational screening exams	Appropriate to exposures

a. PRP

b. Flying status

Enter numeric class in sub block. Dates in DDMMMYYYY.

Immunization	Immunization	Immunization
a. Hep A #1	f. MMR #1	j. TD (q 10 yrs) (Last)
b. Hep A #2	g. MMR #2	k. TD (Due)
c. Hep B #1	h. Pneumococcus	l. Yellow fever (Last)
d. Hep B #2	i. Polio (OPV=0, IPV=I)	m. Yellow fever (Due)
e. Hep B #3

Immunization	Notes	(1)	(2)	(3)	(4)	(5)	(6)	(7)
n. Typhoid	Oral=0, Typhim VI=1, Typhoid USP=2 (dates)
o. Anthrax	(1) Initial, (2) 2 wk, (3) 4 wk, (4) 6 mo, (5) 12 mo, (6) 18 mo
p. PPD — mm	Enter mm reading
p. PPD — date	Enter date read
q. Influenza	Dates
r. Varicella	Dates
s. Meningo	Dates
t. Adeno	Dates
u. Japanese B encephalitis	Dates
	Dates
	Dates

* G6PD = Glucose-6-phosphate dehydrogenase.

a. DNA — date

b. Blood type — date / result

c. G6PD* — date / result

d. Sickle cell — date / result

e. Permanent profile change	Date	P	U	L	H	E	S
(1)
(2)

Location / phase	(a)	(b)	(c)	(d)	(e)	(f)

(1) Predeployment — date
(2) Postdeployment — date

(1) Predeployment — date
(2) Postdeployment — date
c. Chart audit

Additional screening / test rows.

Test	Frequency	(a)	(b)	(c)	(d)	(e)	(f)

f. Glasses / gas mask Rx — date

g. Dental exam (numeric class) — date

h. HIV testing — date

i. Fitness (P=Pass, F=Fail, W=Waiver) — date

i. Fitness — result