Wellnessguide rev3 5 27 16 proof by SEMTX

Telephone Numbers

Michael E DeBakey VA Medical Center (713) 791-1414 1- (800) 553-2278 Beaumont VA OPC (409) 981-8550 1- (800) 833-7734 Charles Wilson VA OPC (Lufkin) (936) 671-4300 1- (800) 209-3120 Conroe VA OPC (936) 522-4000 1- (800) 553-2788 x11979 Galveston VA OPC (409) 761-3200 Lake Jackson VA OPC 979-230-4852 Richmond VA OPC (832) 595-7700 Texas City VA OPC (409) 986-2900 Tomball VA OPC

(281) 516-1505

Katy VA OPC

(281 578-4600

VA Regional Office

(713) 383-1999 1-(800) 827-1000 ii

Your PERSONAL WELLNESS GUIDE BEST health care is attained by understanding and working with your VA Team of Health Care Professionals as an informed patient. This Personal Wellness Guide will make sure that you get the guidance, tests, and immunizations you need to stay healthy. Please read “My HealtheVet” (p. 3) and about the Patient Health Education Resource Center (p. 4).

Table of Contents

Telephone Numbers Table of Contents Welcome Home! My HealtheVet Educational Materials Be Safe Abuse and Neglect Addiction to Drugs Falls Family Planning HIV Infection / AIDS Hepatitis C Medications: Guidelines Military Sexual Trauma (MST) Motor Vehicle Safety Oral Health Care Pain PTSD Rape

Page iii 1 3 4 5 6 7 8 9 10 11 12 124 146 17 18 19 20

iii

Sexually Transmitted Infections Suicide Get Screenings & Immunizations Blood Pressure Breast Examination Cholesterol Colorectal Cancer Screen Mammogram Pap Smear Prostate Cancer Screen Other Preventative Care Manage Stress Depression Low Self-Esteem Be Tobacco Free Limit Alcohol Eat Wisely! Diabetes Heart Disease Heart Failure Be Physically Active Arthritis Strive for a Healthy Weight MOVE! Be Involved In Your Own Healthcare Advance Directives Organ Donation Notes Appointments 2016 Calendar iv

21 22 23 24 25 26 27 28 29 30 31 33 34 35 36 38 39 42 45 46 47 49 50 54 56 59 60 61 67 70

Welcome Home! We are honored to welcome home Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn (OEF/OIF/OND) Veterans and service members who have recently returned from serving in combat operations. Thank you for your service to our country – Now it’s time to let us serve you! The Veterans Affairs (VA) Administration provides OEF/OIF/OND combat Veterans with cost free VA healthcare for conditions potentially related to their combat service for up to five years following their separation from active duty. The Post Deployment Clinic (PDC) developed to meet the unique healthcare transition needs of returning Iraq Afghanistan combat Veterans who accessing the VA for the first time.

was and and are

The PDC is located on the 1st Floor of the Michael E. DeBakey VA Medical Center (MEDVAMC), east side, closest to Almeda, in room 1B-373. (713)791-1414 x 27034. 1

Once I Arrive at the PDC, What’s Next? To begin with, you will complete a brief screening for signs and symptoms commonly associated with the combat experiences of Veterans of Iraq and Afghanistan. These signs and symptoms may include things related to: • Mental and emotional stress • Alcohol use • Infectious diseases • Embedded fragments • Traumatic Brain Injury (TBI) After the initial screenings you will have the option to complete same day comprehensive Medical and Combat Stress Evaluations. This process can take 2-4 hours of your day. After you complete the screenings and evaluations, you will be provided with follow up appointments to Primary Care, Specialty services or both. OEF/OIF Veteran Program Office

(713) 794-8825

My HealtheVet My HealtheVet (MHV) is the gateway to veteran health benefits and services. It provides access to: • trusted health information • links to Federal and VA benefits and resources • the Personal Health Journal • online VA prescription refill • Secure Messaging with your health care team (after in-person authentication) In the future, MHV registrants will be able manage key portions of their VA medical records online. MyHealtheVet is a powerful tool to help you better understand and manage your health. Ask your healthcare provider or clerk about becoming “in-person authenticated” so you can send secure messages to your healthcare team. For more information call the MyHealtheVet Coordinator Garrick Strong at (713) 791-1414 ext., 23902, or log onto www.myhealth.va.gov. 3

Educational Materials PATIENT EDUCATION RESOURCE CENTER (713) 794-7856 Anytime you feel that you need additional or more specific health related information, contact our Patient Education Resource Center (PERC). If you th are at the hospital, visit the center on 4 floor 4A-400 in the library. Our specialized library staff will research your health related questions and provide you with a personalized health information packet while you wait. There are also many books, pamphlets and brochures on a variety of health topics available to patients and their families. If you are at home and have a question that can’t wait until your next visit, you may call (713) 794-7856 and the requested information will be mailed to your home. The PERC is open Monday-Friday from 7:30AM until 4:30PM. Additional information on how to stay healthy is also available from your local health department. You may also obtain information from the sources in this booklet. Most of telephone numbers are tollfree.

Be Safe Following basic safety rules can prevent many serious injuries. Car accidents are the leading cause of death in Veterans in the early years after returning from deployment. Civilian driving is different than driving in military zones. Be defensive & courteous; avoid “road rage.” Don’t text or talk on cell phones while driving. Always wear safety belts when in a car and never drive after drinking alcohol. Wear helmets on motorcycles or bicycles. Use smoke detectors in your home. Change the batteries every year and once a month, check that the smoke detector works. Keeping a gun in your home can be dangerous. If you do, make sure that the gun and the ammunition are locked up separately and out of reach of children. Keep the temperature of your hot water less than 120ºF to minimize the chance of burns, especially if there are children or older adults living in your home. Prevent falls by older adults (see p. 8). Always lock wheelchairs before getting in and out of them. Use crutches and walkers according to the instructions. For more information call the CDC Consumer Product Safety Commission at 1-(800)-638-CPSC. 5

Abuse and Neglect In this society violence against people occurs with alarming frequency. Domestic or family abuse is violence that can be psychological or sexual as well as physical. Physical, verbal or sexual abuse or even financial neglect is not an acceptable part of any relationship. Violence and domestic abuse happen because someone misuses their power. Often the victim of violence and domestic abuse is made to feel at fault or guilty. Regardless of which form violence takes, it is not the fault of the victim. HAS SOMEONE HURT YOU PHYSICALLY OR EMOTIONALLY IN THE PAST? IS SOMEONE ABUSING YOU NOW?

CALL the Domestic Violence HOTLINE

(713) 528-2121

IF: •You or someone in your family is physically abused or the victim of violence. --OR-•You are concerned about violent behavior in yourself, a family member, or a friend. Physical abuse is a crime, no matter who does it. 6

Addiction to Drugs An addicted person: • is unable to stop using a drug in spite of serious related problems • has strong urges to use a drug • can’t control urges to use the drug even when it causes trouble with family, friends, work, school, money, health or the law. Addicted people often find it hard to believe they have a problem. They may need the drug to feel “normal” or may use the drug to cover up some feelings. But, at the same time, addiction often causes troubles. Recovery from drug addiction begins when the addiction is recognized and the addicted person is willing to seek help. After stopping, it is expected that that that person may feel “sick” for a time. This is withdrawal, which can be dangerous, often needing medical supervision. Treatment usually has three parts: • stop drug use and treat withdrawal • learn how the drug is involved with behavior. • learn warning signs to avoid using again Addicted persons may always have cravings or urges to use the drug, but they can learn to be comfortable and happy without using drugs. If you think you may be addicted to a drug, ask for help from your VA health care provider.

For more information, visit the National Institute on Drug Abuse http://www.drugabuse.gov/. 7

Falls: Be Safe The number of falls and the number of serious injuries from a fall increases with age. The body’s ability to heal decreases with age. Avoiding falls requires counter measures to the aging process in which sense of balance declines, strength weakens, vision deteriorates and reaction time slows. Medications can also affect balance and perception. The following suggestions may help you avoid falls. • get an annual physical and eye examination • check with you doctor about side effects of any medicines you take • participate in an exercise program for agility, strength, balance and coordination • eliminate tripping hazards in your home, install grab bars, handrails and other safety devices • wear properly-fitting shoes with non-skid soles • avoid drinking excessive alcohol • remove throw rugs • provide good lighting in living areas, stairs and halls • remove clutter from pathways • install night lights and at night have a working flashlight handy • avoid sitting or standing up too quickly. 8

Family Planning The birth of a child is a joyful event. It is probably best to have children when you are prepared to take care of them. If you are a sexually active man or woman and not ready to have a child, you should use a reliable method of contraception. Some of the different methods of contraception and their effectiveness in typical use over one year are listed below. Talk with your VA health care provider to determine the best method of contraception for you. Methods of Contraception Reversible Methods •Medications -- birth control pills (92% effective), DMPA (over 99%), implants (over 99%), and shots (over 99%) •Intrauterine Devices (IUDs) -- (92%) •Barrier Methods -- condoms (85%), diaphragms (84%), cervical caps (68-84%), and vaginal sponges (64-82%) •Natural Family Planning Methods (“rhythm method”) -- (80%) •Spermicides (alone) -- foams and suppositories (72%) Permanent Methods •Sterilization -- vasectomy (over 99%) and tubal ligation (over 99%) For more information, visit Texas Depart of State Health Services, “Family Planning in Texas” at http://www.dshs.state.tx.us/famplan/. 9

HIV Infection / AIDS HIV, the Human Immunodeficiency Virus, over years causes the body to progressively lose its ability to fight off infections and certain cancers. Although persons with only HIV infections do not feel or look ill, the HIV infection can progress to serious disease, called AIDS, and result in serious infections and cancers. Importantly, HIV infection is both preventable and treatable. We want to prevent HIV infection. For those already infected, we like to diagnose early and treat properly, so that we can prevent progression to AIDS. If you have risk factors for HIV, you should be tested. If you are infected, call the Special Medicine Clinic (713) 794-7943. How Do You Get HIV? Most people with HIV are infected by having unprotected sex with an infected partner, sharing needles to take drugs or are infected through previous blood transfusions. You cannot become infected with HIV from shaking hands with someone who has it or from volunteering to help people with AIDS. How To Reduce Your Risk Of Getting HIV You can reduce your risk of getting HIV infection by not having sex, by having sex with only one, mutually faithful, uninfected partner or by using latex or polyurethane condoms every time you have sex. You can reduce your risk of getting HIV by not using intravenous drugs and by not sharing needles or syringes.

AIDS Hotline, CDC Nat’l 10

(800) 342-AIDS (800) 232-4636

Hepatitis Â C Â Hepatitis C, a viral liver infection, can severely damage liver tissue especially in persons drinking alcohol. Infection may lead to cirrhosis, possible liver failure or increased risk of liver cancer. Hepatitis C is spread through contact with infected blood and can happen in IV Drug Abuse, sharing equipment to snort cocaine, sharing razors or toothbrushes with infected persons, during chronic hemodialysis, in blood transfusions (prior to 1992), in unprotected sex or anal sex, or among persons who have sex with many different people. Hepatitis C disease is identified by a history of risk factors, a medical examination and laboratory tests. If you have risk factors presently or in the past, you should be tested for Hepatitis C. Hepatitis C can be treated; however, not all patients are candidates for treatment! Successful treatment may require significant changes in the way you live. What you eat and drink and your commitment to a long regimen of treatment are essential for successful treatment.

Medications: Â Guidelines Â Before starting a new medicine, obtain the following information from your pharmacist: 1. 2.

3. 4. 5. 6. 7. 8.

The name of the medicine, and how it helps you? Should you take the medicine with food or on an empty stomach? Should you drink much water when you take the medication? Can you still drink alcoholic beverages? How much medicine should you take at one time and how often? What time of the day should you take the medicine? What kinds of side effects should you expect? What to do if they occur? Can you take this medicine with other medicines you are taking? What can you expect by taking more than one medicine at a time? How should you store the medicine? What to do if you forget to take your medicine? Can you take this medicine before coming in for blood work in the lab, or before appointments? Usually you should take your blood pressure medication before coming for your appointments, even if you are waiting to take others until after your fasting labs (like diabetes medication).

Always let your VA health care providers know if you have a history of drug allergies; serious reactions caused by any medicine; or are prescribed medicines from any other provider. You should not stop taking medicine on your own. The only way to achieve the expected results from medicine is to take it as the provider recommends.

Medications: Refills Prescription refills are not sent automatically. You must request refills to obtain medication. Learn medication refill procedures and call for your refills at least 14 days before you run out. You may order your refills by one of the following means: • calling the Automated Prescription Refill System: o (713) 794-7648 (local) or o 1-800-454-1062 (available 24/7). • Using the MyHealtheVet (p. 3) internet site after you’ve been in-person authenticated at the VA at www.myhealth.va.gov • mailing your refill slips to the pharmacy; or, • writing your refill request on a plain piece of paper and mailing it to the pharmacy. If you do not receive your medication in 14 days, you may call the Outpatient Pharmacy Helpline at (713) 794-7653 or (713) 791-1414 ext. 27648 1-800-454-1062 Monday to Friday from 8:00 AM to 4:30 PM to speak with the pharmacy staff. 13

Military Sexual Trauma (MST) Military Sexual Trauma (MST) is the term used by VA to refer to sexual assault or sexual harassment that occurred during a Veteran’s military service. • MST can occur on or off base and while a Veteran is on or off duty. • Perpetrators can be men or women, military personnel or civilians, commanding officers or subordinates, strangers, friends, or intimate partners. • Veterans from all eras of service have reported experiencing MST. • Both men and women can experience MST with 1 in 5 women and 1 in 100 men reporting to their VA healthcare provider that they have experienced MST. • MST affects both mental and physical health. • VA provides free treatment for all mental and physical health conditions related to MST. • VA system has specialized outpatient, inpatient, and residential care available for MST survivors. (continued on next page) 14

Military Military Sexual Sexual Trauma Trauma (MST), continued (MST), continued

• •Veterans can ask to speak with a clinician Veterans can ask to speak with a clinician of of a particular gender if it make a particular gender if would it would make them feel more comfortable. them feel more comfortable. • •Veterans Veterans and and other other individuals individuals with with questions about MST can can contact this questions about MST contact this facility’s facility’s MST MST Coordinator, Coordinator, Audrey Audrey Dawkins-‐Oliver, LCSW at at 713-‐791-‐1414, Dawkins-‐Oliver, LCSW 713-‐791-‐1414, extension 26881. extension 26881. • •Further support and interventions are are Further support and interventions available via via the the MST Points of of Contact available MST Points Contact (POC) assigned in in all all the the VA VA community (POC) assigned community outpatient clinics. outpatient clinics. • •Questions Questions about about compensations compensations for for disabilities or or injuries resulting from MST disabilities injuries resulting from MST can can be be addressed with Veterans Service addressed with Veterans Service Representative Representative at at Veterans Veterans Benefits Benefits Administration (VBA) through the the VA’s Administration (VBA) through VA’s general information hotline at 1-‐800-‐827-‐ general information hotline at 1-‐800-‐827-‐ 1000. 1000.

15 15

Motor Vehicle Safety Impaired driving is dangerous and causes more than half of all motor vehicle crashes. Motor vehicle crashes are the leading cause of death in Veterans in the early years after returning from deployment. Don’t drive under the influence of alcohol or drugs or ride with somebody who is. You can reduce your chance and your loved one’s chances of dying from a motor vehiclerelated injury by correctly using seat belts and care seats. Wear seat belts and secure children in proper car seats in cars. Wear helmets on motorcycles and bicycles. Don’t text message or talk on a cell phone while driving. For more information, contact the Department of AutoSafety, US Transportation at 1-(800)-424-9393 or online @ http://www.dot.gov/safety.html.

Oral Health Care Good oral health care is important for your teeth and general health. With proper care, your teeth will last you for life. Limit the amount of sweets you eat and soda or juice you drink, especially between meals. Do not smoke, chew or dip tobacco products. Brush after meals with a soft or mediumbristled toothbrush using toothpaste with fluoride. Use dental floss daily. Visit your dentist regularly for checkups. For more information, contact the Texas Department of State Health Services “Oral Health Program” at 512-776-7323, or online http://www.dshs.state.tx.us/dental.

Pain Pain can result from obvious injury but it can also happen because something hidden is wrong with your body’s health. Acute pain gets better and goes away in a short time. Chronic Pain may last months. To help your Health Care Provider treat your pain, write down answers to the following: • How bad is it compared to your worst pain? • When did it start? Does it repeat itself? • Where on your body is the pain? • What are you doing when it starts? • How does it feel? (dull, throbbing, stabbing) • How long does it last? • What have you tried that relieves the pain? • What has not worked to relieve pain? If you are caring for someone else who may be unable to speak because of age, language or disease, his or her pain may be much worse than it appears to be. Call their health care provider for the provider to assess the pain. Reporting pain can start the treatment of pain but remember to tell your provider if the treatment works or does not work. 18

PTSD Post Traumatic Stress Disorder (PTSD) is an anxiety disorder that can follow experiencing or witnessing a life-threatening event that produces intense feelings of fear or helplessness. It can seriously interfere with normal day-to-day life and cause great emotional distress. Symptoms may occur soon after the event to years later and may include: • reliving the trauma • avoiding anything associated with the trauma • feeling nervous or on edge after the trauma. After PTSD is diagnosed, there are a number of ways your health care provider can successfully treat PTSD. There are also effective support groups. Talk to your provider for more information. The National Crisis Hotline is: 1-(800) 659-6994.

Rape Sex with anyone without his or her consent is a wrong. Most often rape occurs because of extreme anger against the victim and the abuse is possibly meant to humiliate or degrade the victim. Drugs and alcohol may be related to these sexual offenses. Results of rape can be physical and mental. Victims should not wash or clean themselves before reporting the rape to the police and being examined by a doctor. Follow the recommendations of the doctor and look for professional crisis counseling. Rape Hotline 713 528-7273 Prevention includes knowing: • Typical behavior of potential attackers • What places to avoid • Avoid drugs and alcohol and those who use drugs and alcohol • Learn techniques of self-defense For more information on prevention call the Women’s Sexual Assault Hotline of Houston, (713) 528-7273 or visit www.hawc.org. 20

Sexually Transmitted Infections STIs can be passed to another person during sex; therefore, use a latex condom every time you have sex (vaginal, anal, or oral). Decreasing the number of your sexual partners may reduce the risk of developing STIs. Being in a mutually monogamous relationship with an uninfected partner (you and your partner only have sex with each other) can also reduce your risk. STIs can also be passed from a pregnant woman to her baby. If you are pregnant, get tested for STIs and seek appropriate treatment to avoid passing the infection to the baby. Many STIs do not have symptoms. You can have an STI without knowing it. Some STIs can be cured with antibiotics if they are treated early. Untreated STIs can cause serious health problems, such as infertility. If you are treated for an STI, your sex partner(s) should also be treated. For more information contact the CDC at (800) them online at 227-8922 or visit http://www.cdc.gov/std. 21

Suicide Suicide is a leading cause of death in the US and is increasing rapidly in specific age groups. Thoughts seriously.

about

suicide

must

taken

If you are having these thoughts: • Look for, visit or call a friend • Go to a Doctor, Nurse or Hospital Emergency Room Immediately If a friend is having these thoughts: • Ask, “Are you thinking about hurting yourself?” Don’t be afraid to ask! • Remove any means of suicide and • Do not leave the person alone. • Take the person to his or her doctor or to an Emergency Room immediately. Suicide is preventable. Asking or talking about suicidal thoughts does not make suicide more likely. Experts agree that talking about it helps. The Veterans Suicide Crisis Line: 1-(800) 273-8255 The National Crisis Hotline: 1-(800) 659-6994 22

Screenings & Immunizations Immunizations ("shots") can prevent some serious diseases in adults. All adults should get a tetanusdiphtheria shot every ten years. At age 65, you should get a pneumococcal ("pneumonia") shot, and a follow up every three years. If you are under the age of 65 and have heart, lung, kidney or liver disease, diabetes, sickle cell anemia, immune system problems (including HIV infection), Hodgkin's disease, lymphoma, multiple myeloma, you may need a pneumococcal shot and yearly Influenza shots regardless of age. Everyone over 6 months of age should get a yearly influenza ("flu") shot. Flu shots must be given each year because the flu virus changes and vaccine must be changed yearly to provide protection against it. One year's shot is not likely to protect you during the next flu season. Flu shots are available only in the fall and winter. At that time you may come in and request flu shot during regular clinic hours even if you do not have an appointment. Older adults should wait until late October to get their flu shot. You may record your shots in the back of this booklet. Ask your healthcare team what screenings and other immunizations are recommended for you such as Zoster vaccine (for shingles) or Pneumovax (for pneumonia). More information, visit http://www.prevention.va.gov or http://www.healthfinder.gov/prevention. 23

Blood Â Pressure Â Have your blood pressure checked at periodic clinic visits or at least every two years, and more often if it is high. It is beneficial to know your blood pressure and to do those things that lower it if it is high. A target blood pressure may be less than 120/80; however, with Hypertension or Diabetes a blood pressure less than 130/80 is a reasonable goal. Getting your blood pressure under control will help protect you from heart disease, strokes and kidney problems. If you have high blood pressure, talk with your VA health care provider about how to lower it by changing your diet, losing excess weight, exercising or (if necessary) taking medicine. If you need to take medicine, be sure to take it every day, as prescribed. Limiting the number of beers and/or alcoholic drinks per day or reducing salt or sodium intake can also help to control high blood pressure. If you need more information on changing your diet or reducing your salt or sodium intake, ask your VA health care provider for advice at your next clinic visit or you may ask for a nutrition consult for additional advice. Record your blood pressures from home or clinic visits in the NOTES on p. 61. 24

Breast Examination For Women

The key to combating breast cancer lies in early detection of changes in breast tissue. Early detection requires three elements: • Regular monthly breast self-examination, • Regular physical check-ups which includes a breast exam by your VA health care provider; and, • Mammography (see pg. 28) Talk with your VA health care provider about how often you need breast exams and about doing breast self-examinations. Your health care provider can teach you proper breast selfexamination techniques. They may also have additional educational materials from the American Cancer Society with specific breast self-examination instructions. For questions on Women’s Health, contact the Women’s Health Program Manager, India Gray-Schmiedlin @ 713-791-1414 x 28314. Breast Cancer Care Coordinator Marlene Cano (713) 791-1414 x 25773 25

Cholesterol Many people should have their cholesterol level checked at least every five years: all men over 35 years, men 25-34 who are at increased risk for heart disease (e.g., obese, family history) or women over 20 who are at increased risk. Testing for cholesterol is done by taking a sample of blood. Too much cholesterol can clog your blood vessels and cause heart disease and other serious problems. If your cholesterol is high, you can lower it by • changing your diet (less saturated fat and trans fats) (p. 40), • losing excess weight (p. 50), • exercising (30 minutes 5 or more times a week) (p. 47); and, • taking medicine (when prescribed, p. 12). Your health care provider may also wish to check your levels of "bad" (LDL) and "good" (HDL) cholesterol. A treatment goal may be to decrease LDL to below 100 and increase HDL. A LDL below 100 may be preferred for most people and especially for someone with Heart Disease, Diabetes or Hypertension. As a general rule, a total blood cholesterol level of less than 200 mg/dl, is desirable. Keep track of your cholesterol test results in the NOTES on p. 61. 26

Colorectal Cancer Screen Colorectal Cancer is the second leading cause of cancer deaths in the United States. Risk factors for colorectal cancer include family history of colon polyps, colon cancer or history of inflammatory bowel disease. If detected at an early stage, colorectal cancer can be successfully treated with surgery. Yearly rectal exam, yearly fecal occult blood testing or colonoscopy every ten years are three tests your VA health care provider may use to screen for colorectal cancer. Individuals 50-75 years old should be screened regularly. Some people 40 years or older should also be screened, especially if you have a close relative who had colon cancer. Regular screening is the only way to detect this cancer early enough to do something about it. Colorectal Cancer warning signs include: • changes in bowel habits (diarrhea, constipation), • changes in bowel appearance (narrow, pencilshaped), • blood in stool; and, • unexplained weight loss. Cancer Information Service (800) 422-6237 National Cancer Institute http://www.cancer.gov/ 27

Mammogram For Women

A mammogram is an x-ray test that can detect a breast cancer when it is so small that it cannot be felt, and when it can be most easily cured. You should talk with your VA health care provider about the recommendations for this screening test (see also p. 235). Women 50 to 69 years old should have a mammogram every 2 year. Recommendations may vary for women without regard to age who are at higher risk of Breast Cancer or have a family history of Breast Cancer. These women may be screened before the age of 50 and at a different frequency. When your next mammogram is due, your provider will submit the appropriate order and give you instructions on how and where to obtain the testing. Keep a record of your mammograms and appointments in the NOTES p. 61. For questions on Women’s Health, please contact the Women’s Health Program Manager, India Schmeidlin-Gray @ 713-791-1414 x 28314. 28

Pap Â Smear Â For Women

Cancer of the uterine cervix is one of the most common cancers that effect women. The Papanicolaou test (also called the Pap test or Pap Smear) is a very effective method of detecting cancerous lesions and of identifying changes in cervical tissue that could later become cancerous. The Pap test is usually done as part of a routine gynecologic examination. Regular pelvic examinations and Pap tests should begin when a woman becomes sexually active, or by age 18 whether she is sexually active or not. Pap tests should continue even after menopause; however, unless there is increased risk for cervical cancer, routine testing can stop at 65. Even women who have had a hysterectomy need regular exams and Pap tests. It is best if pelvic exams with Pap tests are performed once a year. Call your VA health care provider or ask at your next clinic visit to arrange for a Pap test. Keep track of when you have had your Pap Smears in the back of this booklet. 29

Prostate Cancer Screen For Men

Prostate cancer is the second most common type of cancer in men (after skin cancer). Risk factors include African-American race and increasing age. Annual screening for prostate cancer should be considered for men over 50 years of age. The screen may be done with a PSA lab test and/or a digital rectal examination. A sample of blood is necessary for the PSA lab test to be done. A possible benefit of the PSA test and rectal exam is early diagnosis. The PSA testing by itself may not actually reduce death from prostate cancer, though. Unfortunately, many men without prostate cancer may also have positive PSA tests and may have to have additional exams. Having the digital rectal exam at the time of the PSA lab test increases the accuracy of the prostate cancer screening. Talk to your health care team about appropriate screening. Sometimes screening can lead to invasive follow-up procedures. 30

Other Preventative Care Below are additional types of preventive care that your healthcare team may discuss with you when appropriate. With each are the reasons that these measures may be recommended, and may differ by age, gender, health status and family history. AIDS (HIV) Test - If you had a blood transfusion between 1978 and 1985, have injected illegal drugs, have had multiple sexual partners, unprotected sex or any male homosexual activity (see p. 10) Aspirin Therapy - If you are a man 45 years of age or older or a woman 55 years or older, particularly if you have diabetes, high blood pressure, high cholesterol, early heart disease in your family, or if you smoke. Eye Examination - If you are over age 60, over age 40 and black, or have diabetes (at any age) (see p. 42). Glucose Test - If you have had a family member with diabetes or have had diabetes during pregnancy (see p. 43).

Other Preventative Care (continued) Mouth Examination - If, now or in the past, you have consumed much alcohol or have smoked, chewed or dipped tobacco. Skin Examination - If you have had history of skin cancer in your family or much sun exposure. Syphilis, Gonorrhea or Chlamydia Tests - If you have had multiple sexual partners or any sexually transmitted diseases. Thyroid Examination - If you have had radiation treatments of your upper body. Tuberculosis (TB) Test - If you have injected illegal drugs, have a history of heavy alcohol use or have been employed as a health care worker, have been exposed to someone with tuberculosis, have recently moved from Asia, Africa, Central or South America, or the Pacific Islands, or if you have kidney failure or HIV infection, your VA health care provider may recommend a TB skin test. Other preventive screenings – Regardless of age, gender or health status, most veterans should be screened for alcohol abuse, depression, high blood pressure, military sexual trauma, obesity, PTSD and tobacco use. 32

Manage Stress Stress occurs when demands on you become too heavy. Although some stress is unavoidable, too much stress is not healthy. Signs of stress may include: • difficulty sleeping, exhaustion, aches, pains, heartburn or indigestion • changes in bowel or bladder habits • anxiety, sweaty palms, irritability, tension or depression • increased use of cigarettes or alcohol. Your provider may recognize that stress is an underlying problem in your medical history and be related to other problems. Speak to your provider about treating stress: • Counseling • Increasing exercise • Relaxation training • Healthy emotional expression • Time management skills • Positive thinking • Pleasant activities • Meditation or deep breathing exercises If you or someone you know is in an emotional crisis call the Veterans' Hotline at 1-800-273-TALK and press 1 for Veterans. 33

Depression We all feel "down" or “blue" at times. However, if these feelings are very strong or last for a long time, they may be due to a medical illness -depression. This illness can be treated, but patients often do not recognize it. Some of the warning signs of depression are listed below. If you have four or more of these warning signs, you should be sure to talk with your VA health care provider about depression. Do Not Delay! Warning Signs of Depression •Feeling sad, hopeless or guilty (see p. 35) •Loss of interest and pleasure in daily activities •Sleep problems (either too much or too little) •Fatigue, low energy, or feeling "slowed down" •Problems making decisions or thinking clearly •Crying a lot •Changes in appetite or weight (up or down) •Thoughts of suicide or death (see p. 22)

Low Self-‐Esteem Low self-esteem or not feeling very good about you is an experience shared by many people. It can cause and contribute to relationship depression (see p. 34), difficulties, and poor occupational advancements, to name a few of the common problem areas. While anyone can feel a little down on himself or herself occasionally, having several of the following symptoms may suggest that you are suffering the effects of low self-esteem: •

• • • •

One shouldn't expect much from life I am not of much use to anyone What I think or feel is not very important Overall, I feel like a failure At times I feel worthless as a person

If several of these statements describe your feelings, please talk with your VA health care provider about this. He or she can help you decide if seeing a mental health professional would be of benefit to you.

SMOKING & TOBACCO: Be Tobacco Free Don't smoke or use tobacco. If you smoke or use tobacco, QUIT. If you fail the first time, do not give up! Keep trying! By quitting any tobacco use, you can significantly reduce your risk of stroke, cancer of the lung, mouth, throat, pancreas and bladder, heart disease, lung disease, COPD and peripheral artery disease. Use of smokeless tobacco can lead to head and neck cancers, oral cancers, gingivitis and periodontal disease. Tobacco use is the leading cause of preventable death in the United States. Strategies to quit include: set a quit date, enlist support of family and friends, anticipate nicotine withdrawal symptoms and/or remove tobacco products from environment. Review past attempts, identify stress or social triggers and plan ways to handle these.

Be Tobacco Free (cont.) Available therapies include: nicotine replacement products, either over-thecounter or prescription; or perhaps, oral medications like Bupropion or Chantix. Nicotine replacement therapies combined with behavioral counseling have been shown to be very effective. If you are interested in smoking cessation, please speak with your healthcare provider who can refer you, or call the Tobacco Cessation Lead Clinician @ (713) 791-1414 x 23911. Discuss these options with your VA health care provider and make a plan specifically for you.

For information, visit www.ucanquit2.org. Smoking Cessation Helpline 1-(800) QUIT-NOW 37

Limit Alcohol Beer, wine, “hard” liquor all contain alcohol. A regularsized beer (12 oz), an 8 oz malt liquor, a 5 oz glass of wine or a shot of liquor all have the same amount of alcohol. If you choose to drink, drink in moderation, if you are permitted to drink at all. Women should have no more than 1 drink/day; men no more than 2 drinks/day. Avoid “binge drinking” (more than 3 drinks on one occasion for women or those >65 years; more than 4 drinks on one occasion for men. For some veterans, it may be recommended that no alcohol at all is consumed (even beer). There are times not to drink alcohol at all: before and while driving or operating machinery shortly before and while pregnant when taking certain medications (ask your pharmacist). For example, Hepatitis C can’t effectively be treated until all alcohol is stopped and the liver is stable. q with hypertension, diabetes, obesity, depression, hepatitis, sleep disorders and other diseases (ask your provider). q q q

In some people, alcohol use may lead to dependency. If you think you may be drinking more than you should, talk to your provider. Please see the online resources at www.prevention.va.gov http://rethinkingdrinking.niaaa.nih.gov Alcoholics Anonymous 1-(800) 234-1253 Alcohol and Drug Abuse 1-(800) 729-6686 Heart, Lung, Blood Disease, Nat’l Institute (301) 592-8573 www.NHLBI.NIH.GOV 38

Eat Wisely! Eating the right foods will help you live a longer, healthier life. Eat a variety of foods including vegetables, fruits and whole grains. It is important to include low fat dairy products in your diet, and to limit total salt, fat, sugar and alcohol. Many illnesses such as diabetes, heart disease, and high blood pressure can be prevented or controlled through a healthy diet. It is never too late to start eating right. Below are simple guidelines that can be followed for healthier eating: 2010 DIETARY GUIDELINES for Americans • Balance calories with physical activity to manage weight. Visit www.choosemyplate.gov for more info. • Choose healthy foods such as fruits, vegetables, whole grains, fat-free and low-fat dairy products, and seafood to meet your nutrient needs. • Consume fewer foods with sodium (salt), saturated fats, trans fats, cholesterol, added sugars, and refined grains. Please talk to your VA healthcare team first if you plan to make any major changes in your diet. If you wish to talk to a registered dietitian, walk-in to Prime Care Clinic 2 in Houston between the hours of 8am-3pm on a weekday. No consult or appointment needed. For any dietary questions or concerns, please call the Nutrition Clinic at 713-791-1414 ext. 23976 and 24295. 39

Food Groups (Eat Wisely continued) Vegetables and Fruits Choose fresh or frozen vegetables and a variety of fruits. Aim for 5-10 servings per day. Limit canned vegetables and fruit juices. Whole Grains Eat 3 ounces or more of whole-grain products per day. Whole grains should be first on the food’s ingredient list. Salt (sodium) Eat less than 1 teaspoon of salt (about 2,300 mg of sodium) per day. Choose “little added salt” foods. People who are middle-aged or older, have high blood pressure, or who are African American should limit their sodium intake to 1,500 mg of sodium per day and get the recommended daily amount of potassium (4,700 mg/day). Dairy Consume 3 cups per day of fat-free or low-fat milk or milk products (yogurt or cottage cheese). If you can’t consume milk, choose lactose-free milk products and/or calcium fortified foods and beverages, consult with your provider. Protein/Meat Go lean with protein, or choose dry beans or peas. 40

(Eat Wisely continued) Choose extra lean ground beef that is at least â&#x20AC;&#x153;90% lean.â&#x20AC;? Vary your choices. Select fatty fish such as salmon, trout, and herring for good omega-3 fatty acids. Carbohydrates Choose fiber-rich vegetables, fruits, and whole grains. Choose foods and beverages with little added sugar or ones using no-calorie sweeteners. Fats The best cooking methods are to bake, broil, braise, roast, steam, sautĂŠ, poach, grill, or stir-fry. Drain off any fat that appears during cooking. Look for foods low in saturated fats, trans fats, and cholesterol. Eat less than 300 mg of cholesterol each day.

41 41

Diabetic Screening Diabetes is an illness that affects a large number of people. It occurs when there is too much glucose, or sugar, in the blood. Signs of early diabetes include increased thirst and urination, unexplained weight loss, blurred vision, numbness or tingling in the hands or feet, and/or poor wound healing. Uncontrolled, diabetes over time can cause poor circulation, infections that can be hard to treat, nerve damage, blindness, kidney damage and heart disease that can lead to death. If you have diabetes in your family or suspect that you might have symptoms of diabetes, please inform your VA health care provider who can test you with a Blood Glucose Test and Hemoglobin A1c for diabetes. Contact the American Diabetes Association for more information, 1-(800) 342-2383 or online at http://www.diabetes.org.

Diabetes Â (continued) Â Diabetic Laboratory Tests Laboratory tests used to check for diabetes include a Blood Glucose Test that tells exactly how much glucose, or sugar, you have in your blood when it is drawn. Normal Blood Glucose levels should be between 70 and 100 if fasting (no food/beverages in your system). Another test used to measure the glucose level in the blood is a Glycosylated Hemoglobin Test (HgA1c). This test is used to check how much glucose has been in your bloodstream over the past three to four months before the test is done, and is useful to check how well the diabetes has been controlled with treatment. A preferred Glycosylated Hemoglobin Test (HgA1C) for diabetics is less than 6.5%.

Diabetes (continued) Diabetic Follow-Up and Treatment Diabetic patients are advised to use very good foot care. You (or someone you know) should check your feet every day for any sores or redness. You should report any foot problems to your VA health care provider, wear properly fitting shoes and never go barefoot. Once a year, diabetic patients should also have their VA health care provider check their feet when they come to clinic. Diabetic eye exams of the retina should be done by an eye doctor every two years and more frequently if you have “Retinopathy” or you notice your vision getting worse. The most important treatment for diabetes is a diabetic diet that should be adjusted to your body needs and activity level. Please talk with your VA health care provider for advice. You may want to call or visit your clinic to speak with a registered dietitian for additional advice (see p. 39). Medication such as pills and/or insulin may also be needed to lower the blood glucose level. 44

Heart Â Disease Â Heart Disease affects the quality of life of many Americans. Heart attacks are the leading cause of death among adults in the United States. Diabetes, high blood pressure, high cholesterol, smoking, obesity, stress and insufficient exercise are major modifiable risk factors for heart disease. Controlling these conditions will reduce your risk for heart disease. Also read in this Wellness Guide the topics Blood Pressure (p. 24), Cholesterol (p. 26), Diabetes (p. 42), Eat Wisely (p. 39), Be Physically Active (p. 47), MOVE! Program (p. 54), Be Tobacco Free (p. 35) and Strive for a Healthy Weight (p. 50). Warning signs of heart disease may include chest pain, shortness of breath, swelling in the legs and feet, pain in the legs with walking, high blood pressure, or high cholesterol. Patients who have already had a heart attack, angioplasty, and angina, bypass or valve surgery can also improve their health though exercise. Ask your provider for a referral to the Cardiac Rehab Program. The Cardiac Rehab Team will work with you, your family and your health care provider to help you maintain and achieve a higher quality of life. For more information (713) 791-1414 x 26614. 45

Heart Failure Heart Failure is one most frequent diagnosis treated at the Houston VA. Heart Failure happens when the heart does not pump enough blood for the needs of the body. When the heart fails (not stops), blood that should go to the body backs up into the lungs causing lung congestion; called, Congestive Heart Failure. Fluid may also back up other places causing hands, legs, ankles and feet to swell. With Heart Failure, it is very important to: 1. take your medicine as directed 2. do not use salt in your food 3. exercise as your provider directs 4. WEIGH YOURSELF EVERY DAY on the same scale at the same time of day and 5. keep a record of your weight & bring it to your healthcare team at your next clinic appointment. 6. It is advised that you have a scale at home Don’t wait to call until symptoms become severe. If the following symptoms start, SEEK MEDICAL ATTENTION IMMEDIATELY: • problems breathing at night • need more pillows or to sit in a chair to breath comfortably at night • weight gain of 2-3 pounds overnight (or 5-7 pounds in a week) • swelling increase in the hands, legs, ankles or feet. For more information contact the American Heart Association at 1-(800) AHA-USA-1 or visit them online at http://www.heart.org. 46

Be Physically Active Aim to reduce inactivity. Some activity is better than none. Lack of exercise is a major risk factor for heart disease (see p. 45). Make a goal for at least 150 minutes of activity per week (every 10 minutes at a time counts). Try strengthening (resistance or weight lifting) activities at least 2 days/week. Benefits of physical activity include: • strengthening heart and lungs • decreasing blood pressure • decreasing body fat • decreasing bad cholesterol (LDL) • increasing good cholesterol (HDL) • increasing energy level • decreasing stress and depression • controlling or preventing onset of diabetes • strengthen muscles • decreasing the risk of bone injury & falls. Many kinds of physical activity will help you feel better and maintain a healthy weight. Find an activity that is right for you, and set a specified time aside each day for exercise. If you plan to start exercising after a long time without any exercise or if you plan to increase significantly the amount of exercise you do, discuss this first with your healthcare team. 47

Be Physically Active continued

The Houston VA has a Veteran Fitness Center on campus. You need your healthcare Provider’s permission note to use the Fitness Center. Hours M-F 8am-4:30 PM. For information call (713) 791-1414 x27296. Visit www.prevention.va.gov for helpful tips on how to stay physically active! Physical Activity Guidelines for Americans

http://www.health.gov/paguidelines/

National Council on Aging

NIH Senior Health

(202) 479-1200 http://www.ncoa.org

1-‐(800) 222-‐2225

http://nihseniorhealth.gov http://go4life.nia.nih.gov/ President’s Council on Fitness, Sports, & Nutrition (240) 276-9567 http://fitness.gov/npfsm/ http://www.presidentschallenge.org 48

Arthritis Â If you have been experiencing pain, stiffness and possible swelling in or around your joints, then you may be affected by arthritis. There are many types of arthritis and it generally occurs more often in older people. Please check with your VA health care provider if these symptoms last longer than two weeks or if you find that joint pain and stiffness keep you from doing daily tasks that you used to do easily. Things you can do to reduce your chance of getting certain types of arthritis or reduce symptoms if you already have arthritis include: 1. lose or avoid gaining excess body weight, 2. exercise regularly and safely to maintain flexibility, strength and endurance, 3. get adequate rest, 4. protect painful or swollen joints from overuse or excessive weight bearing, 5. take arthritis medication as prescribed if recommended by your VA health care provider, and 6. let your VA health care provider know when you notice changes in your abilities from your arthritis. Arthritis Foundation

http://www.arthritis.org 49

Strive for a Healthy Weight A very serious but preventable health problem in the US is the rapidly increasing number of Americans who are overweight or obese. By simply controlling weight, much of diabetes, hypertension, heart disease and cancer are preventable. q less than 25% of all Americans exercise the minimum of 30 minutes 5 times a week. q Many Americans fail to eat a balanced diet of grains, fruits, vegetables, dairy products and meat. q Veterans are more overweight than the general population (approximately 75% of veterans are overweight). Poor eating habits and inactivity are dangerous to your health. The danger is not how you look; it is how the extra pounds affect your health. Consequences of obesity and inactivity are HARMFUL and may include: • Premature Mortality • Diabetes • Heart Disease, Stroke • Certain Cancers • Hypertension, High Cholesterol • Sleep Apnea • Gall Stones, Arthritis 50

Strive for a Healthy Weight (continued) The good news is that health benefits occur with 5% or more loss of weight, no matter what your starting weight is. Both of the major causes of excessive weight can be changed, but only if YOU are READY to make those changes. Determine your own BMI using the chart on the next page and find what category your weight is in: • < 18.5 = Underweight • 18.5 - 24.9 = Normal Great! Maintain your weight. Weigh yourself at least monthly to monitor. • BMI 25 - 29.9 = Overweight Ask your prime care nurse or doctor about the MOVE Program (pg. 47), Read this booklet for information about healthy eating and exercise. Try to lose weight to achieve a normal BMI. • BMI greater than 30 = Obese Ask your health care provider or nurse about the MOVE Program, or fill out a MOVE 11! questionnaire to get started. Focus on setting small diet and exercise goals to lose 10 lbs at a time, with an initial goal of a 5-10% weight loss. Continued on next page 51

Normal

Overweight

Obese

BMI 2 (kg/m Height) (in)

18.5 – 24.9

25 – 29.9

30 +

91 - 118

119 - 142

143 +

94 - 123

124 - 147

148+

Weight (lb)

97 - 127

128 - 152

153 +

100 – 131

132 – 157

158 +

104 – 135

136 – 163

164 +

107 – 140

141 - 168

169 +

110 - 144

145 - 173

174+

114 - 149

150 - 179

180 +

118 - 154

155 - 185

186+

121 – 158

159 – 190

191 +

125 – 163

164 – 196

197 +

128 – 168

169 – 202

203 +

132 – 173

174 - 206

207 +

136 – 178

179 - 214

215 +

140 – 183

184 - 220

221 +

144 – 188

189 – 226

227 +

148 – 193

194 – 232

233 +

152 - 199

200 - 239

240 +

156 – 204

205 - 245

246 +

Strive for a Healthy Weight (continued) Losing weight or keeping the right weight comes from: • eating right • self monitoring • adequate exercise Set an achievable goal to keep focused on your plan and to appreciate your progress. Make a plan to lose ½ to 2 pounds per week to achieve a weight loss of 5% as your first goal. Make small adjustments at a time in your diet that is easy for you to maintain. “Crash” and “Fad” diets do not maintain permanent weight loss and may lead to health problems. Read more on “Eating Wisely” on p. 39. A modest increase in physical activity can burn those extra calories and will lead to a healthier heart and often a decrease in weight. A goal of 30 minutes of exercise 5 times a week is about right. Read about Being Physically Active on p. 47. If you plan to make big changes in your diet, or start exercising after a long time without exercise, or increase significantly the amount of exercise you do, discuss this first with your health care provider. 53

MOVE! Weight Management Program for Veterans MOVE! is a nationwide VA program to encourage Veterans to control their weight. This program focuses on helping Veterans find safe, long-term solutions to weight management. The MOVE! Team is dedicated to helping Veterans lose weight, keep it off and live a healthier lifestyle. We offer several specialized programs to help Veterans learn and develop skills for proper weight control. Enroll in the MOVE! Program by attending MOVE! 101, or by filling out a MOVE! 11 questionnaires. Please contact the MOVE! Coordinator to answer any questions. q

MOVE! 101 is offered on the 2nd and 4th Thursday of every month in Prime Care Clinic 4 at 9am. No appointment neededjust walk-in! (Continued on next page) 54

MOVE! (continued)

q

Fill out a MOVE! 11 Questionnaire available at any primary clinic.

q

MOVE! Walking Group meets every Monday, Wednesday, and Friday at 8am at the gazebo located behind the main hospital building. Just stop by to join the walking group. (physician approval required)

q

Visit both the MOVE web site for helpful handouts at www.move.va.gov .

q

Join our free Veteran’s Fitness Center. Get your health care provider’s approval first (p. 48). Read about Strive for a Healthy Weight (p. 50), Be Physically Active (p. 47), and EAT WISELY! (p. 39) in this booklet.

q

Contact the MOVE! Coordinator for more information: q 713-791-1414 ext. 26166 55

Be Involved In Your Own Healthcare You as the veteran are the primary manager of your health. Your healthcare team is here to assist and guide you in setting goals and changes to improve or manage your health by providing education, tools, resources and services. What changes are you interested in making? Look at the scale below. Point to the number that describes how important this change is to you. ___________________________________ 0 1 2 3 4 5 6 7 8 9 10_ Now point to the number that describes how confident you feel about making the change. Next, take a moment to think about the following: 1. Ask yourself why you didn’t rate yourself lower in importance or confidence. Do you feel this change is really important? Have you had past success in this area? 2. Ask yourself why you didn’t rate yourself higher in importance or confidence. 3. What do you need as a veteran to feel more confident about making a change, and how can your healthcare team help you? 56

Be Involved in Your Own Healthcare (cont.)

After speaking to your healthcare team, set a SMART goal for yourself: S=Specific M=Measurable A=Attainable R=Realistic T=Timely Based on your SMART goal, write down an Action Plan to work towards your goal. 1. How will you work on your goal? 2. What will you do specifically? 3. When will you do these things? 4. Where will you work on your goal? 5. What is the frequency that you will work on your goal? 6. List the barriers you have to achieving your goal. 7. Write down a plan to overcome these barriers. 8. How will you track your progress, and when will you follow up on your goal?

Be Involved in Your Own Healthcare (cont.)

It is important to give your healthcare team: Any current health problems Any concerns you have about your health Past illnesses Past hospitalizations Be Ready for Your Appointment Write down questions you want to ask your doctor (p. 62). And Remember to Ask for your Next Appointment Prescription Refills Lab Results Use pages 62-69 to keep track of your health, appointments and questions for your healthcare team!

Advance Â Directives Â An Advance Directive is a document you create to control health care decisions if you become mentally or physically unable to make these decisions yourself. 1. Directives to Physicians (known in other states as a "Living Will") let you specify what treatments you would want or not want if there is a terminal or irreversible illness. 2. The Durable Power of Attorney for Health Care lets you appoint someone to make decisions about medical care for you, should you become unable to make them yourself. The VA also offers an Advance Directive group the 1st and 3rd Tuesdays of the month. Only attendance to one of the above sessions is needed. If you would prefer to meet with someone individually to discuss Advance Directive, please contact your VA health care provider, nurse or social worker. 59

Organ Â Donation Â An organ or tissue donor is anyone who is willing to donate organs or tissues to help extend another person's life. Kidneys, heart, liver, lung, pancreas and small bowel can be donated. Bone, skin, heart valves, blood vessels, whole eyes and corneas are tissues that can also be donated. To become an organ or tissue donor you sign a donor card in the presence of two witnesses and carry it with you at all times. It is very important that you inform your family of your wishes to donate. This information can also be added to an Advance Directive. Advanced age or a history of disease does not mean that someone cannot donate. Each donor is evaluated individually for medical suitability at the time of death. In east and south Texas, get more information and donor cards by calling: Life Gift 1-800-633-6562

Notes These additional pages are to record:

• Information from clinic visits o Future appointments o Lab results o Current prescriptions • Information from home such as: daily weights, blood sugars, or blood pressures. • Questions that you want to ask your provider at an upcoming appointment. • Information from other Non-‐VA clinics and doctors such as:

Flu shot Pneumonia shot PPD Shingles shot Colonoscopy Mammogram Pap Smear Advance Directive Medicines 61

Notes: Questions for My Provider

Notes Â

Appointments Â Date Time

Clinic

Appointments Â Date Time

Clinic

Appointments Date Time

Clinic