Download Health Assessment

Annual Health Assessment
For patients 75 and over
Aboriginal and Torres Strait Islander patients 55 and over
To be conducted by the patient's usual GP
ATSI
 0-14 years
Item numbers
 701(<30min)
Non-ATSI
Non-ATSI
Non-ATSI
 Practice
 703(30-45 min)
 Home
 705 (45-60min)
 707(>60min)
Nurse time:
Doctor time:
GP details:
<<Doctor:Name>>
Signature:___________________________________
Patient's Name:
<<Patient Demographics:Full Details>>
Past History:
Allergies:
Smoking:
<<Clinical Details:Smoking>>
Alcohol:
<<Clinical Details:Alcohol>>
Social History:
<<Clinical Details:Social History>>
Family History:
<<Clinical Details:Family History>>
Hearing:
Vision:
Progress notes:
<<Summary:Progress Note (Current)>>
Medications:
<<Clinical Details:Medication List>>
Side effects
 15-55 years
 55+ years
 Practice Home
 715 (ATSI)
Total time:
Date: <<Miscellaneous:Date (long)>>
Interactions
Suggested changes
Webster pack
Carer gives
medications
Yes No
Yes No
Immunisations:
<<Clinical Details:Immunisation List>>
Investigations
<<Summary:Investigation Results (Selected)>>
HEALTH ASSESSMENT
Examination/Observations:
Height measurements
<<Clinical Details:Measurements>>
Weight measurements
<<Clinical Details:Measurements>>
Blood Pressure measurements
<<Clinical Details:Measurements>>
Pulse:
Rhythmn:
Ears:
Other:
Medical Support
Have you seen any other doctor/specialist in the last six
months?
Yes No
Do you get regular health care from any other source?
 Allied/Pharmacist/Alternative/Other
Yes No
Social Support
In the last four weeks was there anyone available to help
you if you wanted or needed help?
 Paid/Unpaid-volunteer/Adequacy
Yes No
Are you responsible for caring for someone else?
Yes No
Do you receive any community services?
Yes No
 Meals on Wheels/’Home Help’/etc
Do you need any community services?
Yes No
 Transport/dressing/bathing/housework/shopping/meal
s/telephone/garden/other
Personal Wellbeing Assessment
In the last four weeks have you been troubled by
problems such as feeling anxious or very unhappy?
Yes No
Do you sometimes have difficulty sleeping?
Yes No
Have you had any problems with continence?
 Bowels/Urine/Related to coughing or sneezing
Yes No
Do you experience any problems with your feet?
Yes No
Home Safety Assessment
Can you easily get up from seats and lounge chairs?
Yes No
Can you easily get in and out of bed?
Yes No
Can you reach and switch on a light from your bed?
Yes No
Do you have floor mats and are they fixed safely?
Yes No
Do you use slip resistant mats in the bathroom?
Yes No
Arthritis: do you have problems with handles, lifting, etc? Yes No
Are there stairs/steps that you have difficulty with?
Yes No
Do you need grab rails in your
Yes No
 Bathroom/toilet/entry/stairs/steps/other?
Personal Mobility Assessment
Can you bend and kneel?
Yes No
Can you climb a full flight of stairs?
Yes No
Can you walk a hundred metres?
Yes No
Can you bath and dress yourself?
Yes No
Have you had a fall in the last three months?
Yes No
Personal Nutrition Assessment
Do you eat three meals a day?
Yes No
Do you eat fruit and vegetables most days?
Yes No
Do you eat dairy most days?
Yes No
Do you have six or more 8 cups of fluid most days?
Yes No
Do you have problems swallowing, eating or your teeth? Yes No
Do you have any health problems that affect the kind of
food you eat?
Yes No
Do you always have enough money for food?
Yes No
Have you lost or gained five kilos or more within the last Yes No
six months and if so for what reasons?
Psychological Assessment:
Memory
Folstein MMSE
Depression
Fitness for driving:
Recommendations:
/30
Yes No