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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