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Download 45-49 Year Old Health Check (MBS Item 717)
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45 - 49 Year Old Health Check <<Practice:Name>> Date: <<Miscellaneous:Date>> <<Patient Demographics:Full Name>> <<Patient Demographics:Full Address>> Phone (Home): <<Patient Demographics:Phone (Home)>> Mobile: <<Patient Demographics:Phone (Mobile)>> I <<Patient Demographics:Full Name>> understand what this health check involves and give consent for this health check to be undertaken. <<Patient Demographics:DOB>> <<Doctor:Name>> Patient’s signature: Date: Patient History Medical History <<Clinical Details:History List>> Medication: <<Clinical Details:Medication List>> Allergies: <<Clinical Details:Allergies>> Immunisation: <<Clinical Details:Immunisation List>> Social History: <<Clinical Details:Social History>> Risk Factor Family History Smoking cigarettes, pipes, cigars Alcohol RISK FACTOR ASSESSMENT Information/ Questions Assessment Intervention/ advice/ information recommended: Tick relevant box add details Alcohol problems Bowel cancer Breast cancer Diabetes Heart disease Other disease <<Clinical Details:Family History>> <<Clinical Details:Smoking>> Yes, details no./day___ No <<Clinical Details:Alcohol>> Never Yes, details How often? Intervention recommended? Yes No Intervention recommended? Yes No, non smoker Alcohol Use: Within guidelines Risky If yes, examples of intervention Assess readiness to quit Offer advice to quit Lifescripts Smoking Assessment, General Guidelines and smoke-free prescription QUIT booklet appointment to discuss smoking Other: Provide information about low-risk alcohol use Assess readiness to address alcohol use GP partners Adelaide February 2009 Acknowledging with thanks the original work done by the Southern Division of General Practice 2007 45-49 Year Old Health Check - Page 1 __g/day How often more than 5 drinks on one occasion?__ In the last 12 months have you had any concerns about your drinking? Yes No Unsure Nutrition ___Portions of fruit/ day ___Portions of Vegetables/ day Number of meals a day?__ Do you choose low fat products? Y/N What kind of fats do you eat? Do you have any concerns about your diet? Yes No How many times a week do you do > 20 minutes of vigorous activity? ____ How many times a week do you do > 30 minutes of walking for exercise? ____ How many times a week do you do > 20 minutes of moderate activity? ____ Physical Activity Weight Have you lost/ gained weight more than 5kg in the last 6 months? Y/N details Have you gained more than 10kg since you were 20 years old? Y/N details High risk Intervention recommended? Yes No Intervention recommended? Yes No Intervention recommended? Yes No Height m Weight kg BMI Waist circumference: cm Is BMI above 25? Y/N Lifescripts -Alcohol use Assessment, General guidelines and low-risk alcohol use prescription appointment to discuss alcohol use Other: Examples of intervention Advise to follow NHMRC guidelines for Australian adults Assess interest in improving nutrition Lifescripts Nutrition Assessment, General Guidelines and healthy eating prescription appointment to discuss nutrition Other: Examples of intervention Assess interest in increasing activity levels Lifescripts physical activity Assessment, General Guidelines and active lifestyle prescription Appointment to discuss physical activity Other: Examples of intervention Assess interest in weight management for the long term Lifescripts weight management Assessment, General Guidelines and healthy weight prescription Appointment to discuss weight management Other: SCREENING FOR HEALTH PROBLEMS Information/ Assessment Intervention/ advice/ Questions information recommended: Risk Factor “Over the last 2 weeks, have you felt down, depressed or hopeless?” No Yes, details Depression Intervention recommended? Yes No “Over the last 2 weeks, have you felt little interest or pleasure in doing things?” No Yes, details Osteoporosis Any risk factors for osteoporosis? Low trauma fracture Loss of height Thoracic kyphosis Low mobilisation Average Risk High Risk Examples of intervention Suicide risk assessment Counselling CBT Pharmacotherapy Referral to psychologist Referral to psychiatrist Appointment to discuss mental wellbeing Mental Health Plan Other: Examples of intervention Advice on: Calcium, vitamin D Physical exercise smoking/ alcohol/ caffeine GP partners Adelaide February 2009 Acknowledging with thanks the original work done by the Southern Division of General Practice 2007 45-49 Year Old Health Check - Page 2 Diabetes Cholesterol/ Lipids Medication (eg long term steroids) PHx eating disorder Chronic liver or renal disease Malabsorption Thyroid disease Inflammatory arthropathies Poor diet Excess alcohol/caffeine Limited sun exposure Women: history of > 6 months amenorrhoea Use AUSDRISK Tool to assess risk of developing type 2 diabetes. If you do not wish to use this tool check: History of raised BGL/ IGT/ Diabetes Family History of DM Overweight Sedentary lifestyle Ethnicity Women: gestational diabetes or large baby Women: PCOS When was your cholesterol last tested? Calcium and Vitamin D supplements Investigations if high risk, eg: BMD Vitamin D levels appointment to discuss bone health Intervention recommended? Yes No Examples of intervention Fasting blood glucose to confirm status Refer to Lifestyle Modification Program Lifestyle risk factor counselling If DM appointment to discuss diabetes Refer to Diabetes Educator Develop GPMP Other Order Fasting Blood Lipids Examples of intervention Lifestyle risk factor counseling Pharmacotherapy if eligible appointment to discuss lipids Other Examples of intervention Further investigation Discuss renal function Other Assess absolute cardiovascular risk Kidney Function Bowel Cancer Screening Urinalysis Leuco: Protein: Blood: Other: Are you aware of bowel cancer screening? Examples of intervention Information about Bowel Cancer Screening Other: Other issues Risk Factor ASSESSMENT FOR WOMEN ONLY Information/ Questions Assessment Intervention/ advice/ information recommended: Cervical Cancer When was you last pap test (if has intact uterus)? What was the result? Breast Screening Are you aware of Breast Screen/ Mammogram screening? Examples of intervention If more than 2 years, make appointment for pap smear Other: Examples of intervention Information about Breast Cancer GP partners Adelaide February 2009 Acknowledging with thanks the original work done by the Southern Division of General Practice 2007 45-49 Year Old Health Check - Page 3 Other: Other relevant issues Risk Factor Information/ Questions Prostate Cancer Family History? Urine Symptoms? ASSESSMENT FOR MEN ONLY Assessment Intervention/ recommendation: Examples of intervention Information about Prostate Cancer Other: Other relevant issues EXAMINATION Significant Findings Intervention required: Examine Blood Pressure Systolic Diastolic Examples of intervention Assess absolute cardiovascular risk Lifestyle risk factor counseling Pharmacotherapy if eligible Other Examples of intervention Lifestyle counseling re sun exposure Appointment for biopsy/ excision Referral Other: Add values to weight management above Aim: Skin examination for skin cancer and pre-cancerous lesion Weight Height: Weight: BMI: Waist circumference: Other relevant issues Follow up appointment with results: SUMMARY OF RESULTS Test Result Fasting Glucose Fasting Lipids Total Cholesterol: Triglycerides: HDL: LDL: Normal? Intervention required: Examples of intervention Further investigations Lifestyle risk factor counseling Appointment to discuss diabetes/ impaired glucose tolerance Examples of intervention Lifestyle risk factor counseling Pharmacotherapy if eligible Appointment to discuss lipids Other Other GP partners Adelaide February 2009 Acknowledging with thanks the original work done by the Southern Division of General Practice 2007 45-49 Year Old Health Check - Page 4
