Primary care:
A primary care provider is established to become familiar with past medical history of the patient so that any health problems are thoroughly addressed and managed with long term treatment goals and allows new problems to be identified. Maintain the relationship with the primary care provider in case of unexpected illness. The primary care physician generally completes a comprehensive history and physical exam every year to identify new health problems. A focused history and physical is performed on any new diagnosis. A screening for diseases such as diabetes, high cholesterol and hypertension is done. In adults with one or more new or chronic illnesses, the physician generally specifies more frequent follow-up intervals.
Obesity:
The American Medical Association (AMA) adopted a new policy in June of 2013 to classify obesity as a disease. This move was made to improve research, education, and development of treatment for obesity while at the same time reducing the stigma of being overweight (46). The USPSTF recommends counseling and lifestyle modifications for adults with obesity. Obesity is defined as a body mass index (BMI) of over 30 kg per meter squared (47). Please see the section on Weight Loss in Preventive Health Advisor.
High blood pressure:
According to the U.S. Preventive Services Task Force (USPSTF), all adults over 18 years old should be screened for high blood pressure (bp), and the USPSTF has determined that control of bp below 135/80 decreases cardiovascular mortality and cardiac events (17). The risk of cardiac events is higher in diabetics than those who do not have diabetes. Elevated blood pressure does not cause symptoms and if is not controlled over time, may lead to heart disease and/or increase the risk of stroke and diabetes. If blood pressure is found to be over 135/80 mmHg, the USPSTF recommends screening for diabetes mellitus (16).
Blood tests:
Yearly fasting blood tests: These tests are advised at the annual wellness visit to proactively manage health, and help determine risk of stroke, cardiovascular disease, diabetes, and many other diseases. The recommended tests include complete blood count with differential (CBC with diff), comprehensive metabolic panel with kidney function tests (sodium, potassium, bicarbonate, bood urea nitrogen, creatinine, glucose, calcium) and liver function tests (AST, ALT, LDH, GGT, bilirubin, and alkaline phosphorus, albumin, total protein), uric acid, magnesium, phosphorus (inversely related to fructose consumption), lipid profile, homocysteine (measures systemic inflammation and evaluates stroke risk) C-reactive protein (for heart attack risk), DHEA sulfate, free and total testosterone, progesterone, estradiol (for both women and men), 25-OH vitamin D (retest after on 3 months of vitamin D3), vitamin B12 level, iron profile, thyroid function tests with TSH, free T4 and T3, fasting blood glucose, hemoglobin A1C (3 month average serum glucose), PSA for males over age 45 (not reliable for prostate cancer screening but for prostate inflammation)
EKG screening:
Yearly EKG screening is in general, advocated by many primary care physicians.
Adult vaccination schedule:
Influenza vaccination is given each year in October (2). For requirements of other adult vaccines and for more information see the Centers of Disease Control Website (7): http://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. In this age group, consider vaccination for Hepatitis A & B, Pneumococcus, Herpes zoster (shingles), tetanus, Haemophilus influenzae, Meningoccocal, and Varicella
Chest X-ray:
Chest X-ray screening may be indicated by your primary care physician.
Tobacco abuse:
Avoid substance abuse and tobacco abuse. Quit tobacco use as soon as possible by using a combination of several methods to assist in cessation. For instance, combine nicotine replacement with at least one additional method such as an exercise program, hypnosis, or formal counseling such as support groups. The recommendation to counsel patients to stop smoking, stop using tobacco products, and provide methods of cessation is reinforced by the USPSTF (25). Many resources are available to assist in smoking cessation such as the online sites http://smokefree.gov/, http://www.cdc.gov/tobacco/campaign/tips/quit-smoking/ and the phone number for free help 1-800-QUIT-NOW.
Hydration:
Inadequate hydration may be associated with adverse health conditions. Good hydration maintenance may prevent chronic diseases such as kidney stones, constipation, exercise induced asthma, elevated blood glucose, urinary tract infections, high blood pressure, coronary artery disease, thrombosis leading to embolism, ischemic stroke, and lung disease (11). The average sized person eating an average diet in the U.S. consumes 2.5 liters per day of water per day (10). Consume adequate water for hydration (at least 2 liters or 8, 8 ounce glasses per day), unless a water limiting diagnosis such as heart failure or cirrhosis is present which may limit fluid intake to as low as 1 liter per day.
General nutrition:
Ensure nutritional needs are met by observing daily allowances of vitamins and minerals preferably through diet rather than taking supplements. Consume a diet low in fat with the lowest possible amount of cholesterol. The current mainstream recommendation is 300 mg or less per day. Intake of lower than 200 mg per day of cholesterol may yield even better health results. Limit saturated fats to as low as possible, avoid fried foods, and select fats containing the highest amounts of monounsaturated oils such as canola oil and olive oil. Include a handful of tree nuts in the diet once per day such as walnuts, Brazil nuts or pecans. Limit red meat to once per week, limit poultry and seafood to 3 times per week. Oily fish may be of benefit 3 times per week. Consume at least 5 fruits and vegetables per day in the form of whole foods, vegetables and fruits. Processed foods should be avoided.
Exercise:
All patients should seek physician advice prior to any rigorous exercise. The primary care physician may recommend safe exercise for patients according to the individual demographics and medical history. For basic guidelines on recommending safe exercise for patients, look here. According to the American College of Sports Medicine (ACSM) and the American Heart Association (AHA), older adults need moderate-intensity (between 5-6 on a 10-point scale) aerobic endurance activity for a minimum of 30 min which can be achieved in short 10 minute sessions on five days each week or vigorous-intensity aerobic, (rated a 7-8 on a 10-point scale) activity for a minimum of 20 min on 3 days each week. Adults should also perform muscle-training exercises 2-3 days each week using a variety of exercises (8-10 exercises involving the major muscle groups). For each exercise, 10-15 repetitions are recommended to improve strength. Additionally, older adults at risk of falling should do flexibility exercises at least 2 or 3 days each week to maintain or improve balance (3). For more information on Aerobic Exercise and Resistance Training benefits, see these sections in Preventive Health Advisor.
High risk behaviors:
Avoid behavior with excessive risk including high speed driving, motorcycle riding without a helmet, unprotected sex outside marriage, multiple sex partners.
Sun exposure:
Prevent sun damage of the skin and eyes with sunblock (at least spf 30) and UV eye protection. According to the U.S. Preventive Services Task Force (USPSTF), all young adults age 24 years and younger are specifically recommended to receive counseling on minimizing their exposure to ultraviolet radiation to reduce risk of skin cancer. USPSTF reviewed epidemiology of skin cancer due to UV exposure. They found that children, adolescents, and young adults are at a moderate risk for skin cancer, while adults older than this have a smaller increase in risk. The USPSTF states that sunlight exposure is linked to all 3 types of skin cancer. Melanoma is the rarest but has the highest mortality. Squamous cell is more common but is accountable for a small number of cancer deaths. Basal cell does not usually metastasize and doesn’t result in cancer deaths. Per the USPSTF, counseling should be based on prevention or minimizing sun exposure with clothing, broad spectrum sunblock with minimum of 15 spf, avoiding midday sun 10 am to 3 pm, and avoidance of indoor tanning beds. (48)
Sexually transmitted infections:
According to the U.S. Preventive Services Task Force (USPSTF), all sexually active adults at increased risk for sexually transmitted infections are recommended to have high-intensity behavioral counseling to prevent these infections. According to the USPSTF, adults with current sexually transmitted infections or within the past year are considered to be at increased risk for future sexually transmitted infections. They are also considered increased risk by the USPSTF if adults have multiple current sexual partners or if the medical practice population has a high rate of sexually transmitted infections. Routine gonorrhea screening in men and women at low risk of infection is recommended against by the USPSTF. (37,49)
HIV:
Any individual at increased risk of HIV infection is strongly recommended by the U.S. Preventive Services Task Force (USPSTF) to be screened for HIV. Adults with an increased risk as quoted by the USPSTF includes: “men who have had sex with men after 1975; men and women having unprotected sex with multiple partners; past or present injection drug users; men and women who exchange sex for money or drugs or have sex partners who do; individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users; persons being treated for sexually transmitted diseases (STDs); and persons with a history of blood transfusion between 1978 and 1985. Persons who request an HIV test despite reporting no individual risk factors may also be considered at increased risk, since this group is likely to include individuals not willing to disclose high risk behaviors. There is good evidence of increased yield from routine HIV screening of persons who report no individual risk factors but are seen in high-risk or high-prevalence clinical settings. High-risk settings include STD clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs.” (16)
Syphilis:
All adults should be screened for syphilis infection if at an increased risk. which include men who have sex with men and engage in high-risk sexual behavior, commercial sex workers, persons who exchange sex for drugs, and those in adult correctional facilities. Per the USPSTF, prevalence is higher in communities of the southern U.S., within cities, and in African American and Hispanic ethnicities. Routine screening of person with no related symptoms (asymptomatic) who are not at increased risk for syphilis infection is recommended against by the USPSTF. (24)
Alcohol use:
Primary care physicians are recommended by the U.S. Preventive Services Task Force (USPSTF) to screen all adult patients for the misuse of alcohol (39). The most widely used screening tool for alcoholism may be found here: CAGE questionaire. The primary goal for alcoholics is complete abstinence. Interventions options include behavioral therapy, therapy with health professionals which specialize in abuse, and medications which can either reduce the craving, or medication which causes an adverse physical reaction if alcohol is combined with it. Alcoholism medications to curb craving include nalmefene, also known as Revex, which has been found to be effective for the prevention of relapse (12). Another anti-craving agent is naltrexone which showed a significantly greater rate of abstinence than placebo (13). Agents which cause aversion reactions after drinking alcohol include disulfiram and calcium carbimide. These agents were also found to produce an abstinence rate in outpatient alcoholics of over 50% in a 9 year period and were tolerated well long term (14). An abrupt discontinuation of alcohol may not only lead to a life-threatening withdrawal syndrome, it may place patients at higher risk of stroke. Please see the section on Ischemic Stroke in Preventive Health Advisor. Alcohol use in moderation is best consumed in the form of red wine which may help non-alcoholics achieve several long term health benefits. See also the section on Red Wine and the section on Alcohol Consumption Risks and Benefits in Preventive Health Advisor.
Colorectal cancer screening:
The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer for all individuals 50 – 75 years old with either fecal occult blood testing every year, fecal occult blood testing every 3 years plus sigmoidoscopy every 5 years, or screening colonoscopy every 10 years (15). The routine screening for colorectal cancer among adults age 76 to 85 years is not recommended by the USPSTF unless not previously screened and benefit outweighs the risks and the rationale to not screen after age 75 is the fact that the benefit is not seen until 7 years later in clinical trials (15). For those age 85 years and older, the USPSTF recommends against screening for colorectal cancer since risk of mortality outweighs the benefits (15). Since 2008, the American College of Radiology, the U.S. Multi-Society Task Force on Colorectal Cancer, and the American Cancer Society have also collectively favored testing with annual guaiac-based fecal occult blood test with 2 to 3 stool samples, annual fecal immunochemical test, or annual stool DNA test and if positive, perform flexible sigmoidoscopy (with insertion to 40 cm splenic flexure every 5 years), colonoscopy every 10 years, double contrast barium enema every 5 years, and computed tomography colonography every 5 years (54). According to the USPSTF, the American College of Physicians, American Academy of Family Physicians, American College of Preventive Medicine, and Centers for Disease Control and Prevention have similar recommendations or have endorsed the USPSTF recommendation (15).
Depression:
The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression if appropriate professionals are available for accurate diagnosis, effective treatment, and follow-up (36).
Sleep:
A regular sleep schedule and adequate rest of 6-9 hours per night is recommended. Avoid erratic sleep patterns which can put one at higher risk for premature heart disease or cancer.
Awareness:
Keep a watchful eye for unusual changes of the body. Many people have come to see their doctor after a certain concerning problem has been going on for a year or more after the problem has become much worse. Look for wounds that are not healing, skin problems, ongoing cough, persistent shortness of breath, ongoing pain, lasting fevers, unexplained weight loss, lumps and other new problems which do not go away.
Fall prevention in older adults:
To prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls, the U.S. Preventive Services Task Force (USPSTF) recommends exercise or physical therapy and vitamin D supplementation. This was recommended by USPSTF as a result of determining that each these interventions have a moderate net benefit. The risk of fall and morbidity after falls is greater than the risk associated with taking vitamin D, exercising, or participating in physical therapy. (55)
The U.S Preventive Services Task Force
The U.S Preventive Services Task Force is one of the most credible and respected authorities in Preventive Medicine with extensive research backing all of their recommendations. Click here to review these.
References:
1.Preventive Services Recommended by the USPSTF: Guide to Clinical Preventive Services, 2012. October 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section1.html
2.Centers for Disease Control and Prevention 1600 Clifton Rd. Atlanta, GA 30333, USA. 800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 – Contact CDC–INFO. http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
3.Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007 Aug;39(8):1435-45. http://circ.ahajournals.org/content/116/9/1094.full.pdf
4American Academy of Pediatrics, Rose SR; Section on Endocrinology and Committee on Genetics, American Thyroid Association, Brown RS; Public Health Committee, Lawson Wilkins Pediatric Endocrine Society, Foley T, Kaplowitz PB, Kaye CI, Sundararajan S, Varma SK. Update of newborn screening and therapy for congenital hypothyroidism. Pediatrics. 2006 Jun;117(6):2290-303. http://www.ncbi.nlm.nih.gov/pubmed/16740880
5.American Academy of Pediatrics, Joint Committee on Infant Hearing. Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs.Pediatrics. 2007 Oct;120(4):898-921. http://www.ncbi.nlm.nih.gov/pubmed/17908777
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7.Food and Nutrition Board, Institute of Medicine. Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington, DC: National Academy Press, 2001. http://iom.edu/~/media/Files/Activity%20Files/Nutrition/DRIs/DRI_Elements.pdf
8.Centers for Disease Control and Prevention 1600 Clifton Rd. Atlanta, GA 30333, USA. 800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 – Contact CDC–INFO . http://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
9.Montenegro-Bethancourt G, Johner SA, Remer T. Contribution of fruit and vegetable intake to hydration status in schoolchildren. Am J Clin Nutr. 2013 Aug 21. http://www.ncbi.nlm.nih.gov/pubmed/23966431
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11.Manz F, Wentz A. The importance of good hydration for the prevention of chronic diseases. Nutr Rev. 2005 Jun;63(6 Pt 2):S2-5. http://www.ncbi.nlm.nih.gov/pubmed/16028566
12.Mason BJ, Salvato FR, Williams LD, Ritvo EC, Cutler RB.A double-blind, placebo-controlled study of oral nalmefene for alcohol dependence. Arch Gen Psychiatry. 1999 Aug;56(8):719-24. http://www.ncbi.nlm.nih.gov/pubmed/10435606
13.Kranzler HR, Wesson DR, Billot L; DrugAbuse Sciences Naltrexone Depot Study Group. Naltrexone depot for treatment of alcohol dependence: a multicenter, randomized, placebo-controlled clinical trial.Alcohol Clin Exp Res. 2004 Jul;28(7):1051-9. http://www.ncbi.nlm.nih.gov/pubmed/15252291
14.Krampe H, Stawicki S, Wagner T, Bartels C, Aust C, Rüther E, Poser W, Ehrenreich H.Alcohol Clin Exp Res. Follow-up of 180 alcoholic patients for up to 7 years after outpatient treatment: impact of alcohol deterrents on outcome. 2006 Jan;30(1):86-95. http://www.ncbi.nlm.nih.gov/pubmed/16433735
15.U.S. Preventive Services Task Force. Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. AHRQ Publication 08-05124-EF-3, October 2008. http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm
16.Screening for Type 2 Diabetes Mellitus in Adults, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiab.htm
17.Screening for High Blood Pressure in Adults, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspshype.htm
18.U.S. Preventive Services Task Force. Screening for Lipid Disorders in Adults: U.S. Preventive Services Task Force Recommendation Statement. June 2008. http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm
19.U.S. Preventive Services Task Force. Screening for Hepatitis B Virus Infection in Pregnancy: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement. AHRQ Publication No. 09-05134-EF-1, June 2009. http://www.uspreventiveservicestaskforce.org/uspstf09/hepb/hepbpgrs.htm
20.U.S. Preventive Services Task Force. Screening for Osteoporosis: Recommendation Statement. AHRQ Publication No. 10-05145-EF-2, January 2011. http://www.uspreventiveservicestaskforce.org/uspstf10/osteoporosis/osteors.htm
21.U.S. Preventive Services Task Force. Screening for Rh (D) Incompatibility: Recommendation Statement. February 2004. http://www.uspreventiveservicestaskforce.org/3rduspstf/rh/rhrs.htm
22.American College of Obstetricians and Gynecologists. Obstet Gynecol. ACOG Practice Bulletin No. 75: Management of alloimmunization during pregnancy. 2006 Aug;108(2):457-64. http://www.ncbi.nlm.nih.gov/pubmed/16880320
23.Screening for Syphilis Infection in Pregnancy, Topic Page. May 2009. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspssyphpg.htm
24.U.S. Preventive Services Task Force. Screening for Syphilis Infection: Recommendation Statement. July 2004. http://www.uspreventiveservicestaskforce.org/3rduspstf/syphilis/syphilrs.htm
25.U.S. Preventive Services Task Force. Counseling to Prevent Tobacco Use and Tobacco-Related Diseases: Recommendation Statement. November 2003. http://www.uspreventiveservicestaskforce.org/3rduspstf/tobacccoun/tobcounrs.htm
26.Screening for HIV, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm
27.U.S. Preventive Services Task Force. Screening for Visual Impairment in Children Ages 1 to 5: Clinical Summary of U.S. Preventive Services Task Force Recommendation. AHRQ Publication No. 11-05151-EF-3, January 2011. http://www.uspreventiveservicestaskforce.org/uspstf11/vischildren/vischildsum.htm
28.Screening for Congenital Hypothyroidism, Topic Page. U.S. Preventive Services Task Force. March 2008. http://www.uspreventiveservicestaskforce.org/uspstf/uspscghy.htm
29.Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum, Topic Page. July 2011. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsgononew.htm
30.Screening for Phenylketonuria (PKU), Topic Page. U.S. Preventive Services Task Force. March 2008. http://www.uspreventiveservicestaskforce.org/uspstf/uspsspku.htm
31.Screening for Sickle Cell Disease in Newborns, Topic Page. September 2007. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspshemo.htm
32.Nelson HD, Bougatsos C, Nygren P. Universal Newborn Hearing Screening: Systematic Review to Update the 2001 U.S. Preventive Services Task Force Recommendation. AHRQ Publication No. 08-05117-EF-4, July 2008. http://www.uspreventiveservicestaskforce.org/uspstf08/newbornhear/newbornart.htm
33.U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. AHRQ Publication No. 05-0569-A, February 2005. http://www.uspreventiveservicestaskforce.org/uspstf05/aaascr/aaars.htm
34.U.S. Preventive Services Task Force. Screening for Obesity in Children and Adolescents: Recommendation Statement. AHRQ Publication No. 10-05144-EF-2, January 2010. http://www.uspreventiveservicestaskforce.org/uspstf10/childobes/chobesrs.htm
35.U.S. Preventive Services Task Force. Screening for Depression. May 2002. http://www.uspreventiveservicestaskforce.org/3rduspstf/depression/
36.Screening for Major Depressive Disorder in Children and Adolescents, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm
37.Meyers, D., Wolff, T., Gregory, K., et al. USPSTF Recommendations for STI Screening. Originally published in Am Fam Physician 2008;77:819-824. http://www.uspreventiveservicestaskforce.org/uspstf08/methods/stinfections.htm
38.U.S. Preventive Services Task Force. Screening for Iron Deficiency Anemia—Including Iron Supplementation for Children and Pregnant Women: Recommendation Statement. Publication No. AHRQ 06-0589, May 2006. http://www.uspreventiveservicestaskforce.org/uspstf06/ironsc/ironrs.htm
39.Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrin.htm
40.Screening for Breast Cancer, Topic Page. July 2010. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm
41.Genetic Risk Assessment and BRCA Mutation Testing for Breast and Ovarian Cancer Susceptibility, Topic Page. April 2013. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrgen.htm
42.Liquid-Based Cytology and Human Papillomavirus Testing to Screen for Cervical Cancer. A Systematic Review for the U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf11/cervcancer/cervcancerupd.htm
43.Aspirin for the Prevention of Cardiovascular Disease, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm
44.Folic Acid to Prevent Neural Tube Defects, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsnrfol.htm
45.Screening for Asymptomatic Bacteriuria in Adults, Topic Page. July 2008. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbact.htm
46.Lazarus, Ethan. AMA House of Delegates Adopts Policy to Recognize Obesity as a Disease. American Society of Bariatric Physicians. Last Updated on Friday, 21 June 2013. Accessed 8/29/2013. http://www.asbp.org/asbpmedia/newsreleases/71-asbparticle2-3.html
47.Screening for and Management of Obesity in Adults, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsobes.htm
48.Behavioral Counseling to Prevent Skin Cancer, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsskco.htm
49.Behavioral Counseling to Prevent Sexually Transmitted Infections, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsstds.htm
50.Chemoprevention of Breast Cancer, Topic Page. July 2002. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrpv.htm
51.Screening for Breast Cancer, Topic Page. July 2010. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm
52.Screening for Cervical Cancer, Topic Page. April 2012. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm
53.Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: Draft Recommendation Statement. AHRQ Publication No. 12-05167-EF-2. http://www.uspreventiveservicestaskforce.org/uspstf12/ipvelder/draftrecipvelder.htm
54.Levin B, Lieberman DA, McFarland B, Andrews KS, Brooks D, Bond J, Dash C, Giardiello FM, Glick S, Johnson D, Johnson CD, Levin TR, Pickhardt PJ, Rex DK, Smith RA, Thorson A, Winawer SJ; American Cancer Society Colorectal Cancer Advisory Group; US Multi-Society Task Force; American College of Radiology Colon Cancer Committee. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008 May;134(5):1570-95. doi: 10.1053/j.gastro.2008.02.002. Epub 2008 Feb 8. http://www.ncbi.nlm.nih.gov/pubmed/18384785
55.Prevention of Falls in Community-Dwelling Older Adults, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm