Tricity Family Medicine & Urgent Care

Patient's First Name * Patient's Last Name: * Patient's Date of Birth: *

Breast Cancer Screening - Women Only

Recommended to patients between the age 52 and 74 years to have one or more mammograms at least every 2 years.

Ever had a Mammogram? If yes, when was the last? Doctor's Office Information where mammogram performed:

Cervical Cancer Screening- Women 50-65 years only

Recommended PAP test every 3 years or PAP test and HPV test every 5 years.

Ever had a PAP test? If yes, when was the last? Ever had a HPV test? If yes, when was the last? Doctor's office information where cervical cancer screening performed:

Colorectal Cancer Screening- Men and Women 50- 75 years only

*Stool Blood Test* - Recommended every year OR *Sigmoidoscopy* - Recommended every 5 years OR *Colonoscopy* - Recommended every 10 years (if no polyps in past exams)

Ever had a Stool Blood Test? If yes, when was the last? Ever had Sigmoidoscopy? If yes, when was the last? Ever had Colonoscopy? If yes, when was the last? Doctor's Office Information where Colorectal screening performed:

Prostate Cancer Screening - Men Only

Ever had a PSA test? If yes, when was the last? Doctor's Office Information where Colorectal screening performed: Are you due for Annual Wellness Exam/ Physical Exam?