Preventive Care Checklist Forms


Male Preventive Care Checklist Form [PDF] [PDF fillable]
Female Preventive Care Checklist Form [PDF] [PDF fillable]
Preventive Care Checklist Form Explanations [PDF]

The Preventive Care Checklist Form© was most recently updated in 2018. © The forms have been updated with current recommendations to enable family physicians to provide comprehensive, evidence-based care to patients during period health examinations. The forms were re-endorsed through a peer-review process by the College of Family Physicians of Canada, in October 2019.

2019 updates based on the Canadian Task Force on Preventive Health Care recommendations include: recommendations on screening for hepatitis C (2017), lung cancer (2016), colorectal cancer (2016), cognitive impairment (2015), abdominal aortic aneurysm (2017), screening for dyslipidemia (2016), folic acid counselling for women of childbearing age (2015), nutritional intake of vitamin D and calcium (2010, 2016), and immunizations (2014, 2017). Recommendations lacking evidence were not included. An article in the Canadian Family Physician outlining the changes is pending peer review.

In 2002, the authors developed and validated the effectiveness of an easy-to-use Preventive Care Checklist Form© for family physicians to use during adult complete health check-ups.1 Their model was the Rourke Baby Record. The form incorporates recommendations primarily from the Canadian Task Force on Preventive Health Care (CTFPHC) and other sources where the CTFPHC recommendations were not up-to-date. The form also has non-evidence-based components that are a part of routine practice. The forms can be used electronically or photocopied on coloured paper to easily refer back on subsequent visits.

The forms were validated in the PERFORM (Preventive Health, Evidence-based, Recommendation Form) Trial.2 The results showed a dramatic increase in preventive health care. As well, 77% of physicians surveyed at the end of the trial said they would continue to use the forms in their routine care and 85% said it improved their documentation of preventive health care by at least 50%.2


1: Dubey V, Glazier R. Preventive care checklist form. Evidence-based tool to improve preventive health care during complete health assessment of adults. Can Fam Physician. 2006 Jan;52:48-55.

2: Dubey V, Mathew R, Iglar K, Moineddin R, Glazier R. Improving preventive service delivery at adult complete health check-ups: the Preventive health Evidence-based Recommendation Form (PERFORM) cluster randomized controlled trial. BMC Fam Pract. 2006 Jul 12;7:44.