Patient Last Name, First Name Date of Birth Date Provider
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UNITED STATES PREVENTIVE SERVICES TASK FORCE (USPSTF) A AND B RECOMMENDATIONS
ELIGIBLE TEST GENDER AGES OTHER CRITERIA RECOMMENDATION SCHEDULE
Abdominal aortic
aneurysm screening
Men 65 to 75 Ever smoked One-time screening with
ultrasonography
Aspirin preventive All 50 to 59 All the following: >= 10% ten-year cardiovascular
risk, not at increased risk for bleeding, life expectancy
>= 10 years and willing to take low-dose aspirin
daily for >= 10 years
Low-dose aspirin
(81 mg/d)
Blood pressure screening All 18 and older Obtain measurements outside the clinical setting
for diagnostic conrmation before starting
treatment
Screen for hypertension
Breast cancer gene (BRCA)
risk assessment and genetic
counseling/testing
Women Personal or family history of breast, ovarian, tubal
or peritoneal cancer or ancestry associated with
BRCA1 or BRCA2 gene mutations, use familial risk
assessment tool
If positive result on risk assessment
tool then give genetic counseling
and, if indicated after counseling,
genetic testing
Breast cancer preventive
medications
Women Increased risk for breast cancer and at low risk for
adverse medication side eects
Oer risk-reducing medications
such as tamoxifen, raloxifene or
aromatase inhibitors
Breast cancer screening Women 40 and
older
Screening mammography with or without clinical breast examination every 1 to 2 years
Cervical cancer screening Women 21 to 29 Screen with cervical cytology alone every 3 years
30 to 65 As above or hrHPV testing alone every 5 years or hrHPV + cytology every 5 years
Chlamydia screening Women 24 or
younger
Sexually active
Screen for chlamydia
25 and older Increased risk for infection
Colorectal cancer screening All 50 to 75 Screen for cancer
Depression screening All 18 and
older
Screen with adequate systems in place to ensure accurate diagnosis, eective treatment
and appropriate follow-up
Diabetes screening All 40 to 70 Overweight or obese Screen for abnormal blood glucose
and oer or refer if abnormal to
intensive behavioral counseling
interventions to promote a healthy
diet and physical activity
Fall prevention All 65 and older Community-dwelling at increased risk for falls Exercise interventions to prevent falls
Folic acid supplementation All See other
criteria
Planning or capable of pregnancy Take folic acid supplement: 0.4 to
0.8 mg per day
Gonorrhea screening Women 24 or
younger
Sexually active
Screen for gonorrhea
25 and older Increased risk for infection
Healthy diet and physical
activity counseling to prevent
cardiovascular disease
All 18 and
older
Overweight or obese with additional
cardiovascular disease (CVD) risk factors
Intensive behavioral counseling
interventions to promote healthy
diet and physical activity for CVD
prevention
Establish a written screening schedule, such as a checklist, for the next ve to 10 years based on recommendations
from the following resources and the member’s health risk assessment, health status and screening history:
• U.S. Preventive Services Task Force (see below for nonpregnant members)
• Advisory Committee on Immunization Practices
• Age-appropriate preventive services covered by Medicare (see Annual Wellness Visit Guide)
Establish a list of risk factors and conditions that have a recommended intervention (see below table)
