Download Health Assessment Older Person (55+) (DOC)

Medicare Health Assessment for Aboriginal and Torres Strait
Islander Australians (MBS Item 715)
OLDER PERSON HEALTH ASSESSMENT (55+)
Use of a specific form to record the results of the health assessment is not mandatory but the health
assessment should cover the matters listed in the Explanatory Notes at www.health.gov.au/mbsonline
Patient Details
Clinician Details
Name:
Date of Birth:
Age:
Gender:
Work Status:
This patient identifies as being of
Address:
Phone:
Mobile:
Name:
Address:
Qualifications:
Provider No:
origin.
Phone:
Carer Details
Self 
Name:
Address:
Phone:
Patient Consent
Previous Health Assessment
Explanation of health check given
Has the patient had a previous health assessment
Yes  No 
Yes  No 
Patient consent for health check given
Date of last health assessment (if known)
Yes  No 
Date consent was given
Consent given for information to be collected
by:
Services provided by Dr
PATIENTS OVERALL HEALTH
RISK FACTORS IDENTIFIED AND DISCUSSED WITH PATIENT
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TESTS UNDERTAKEN, RESULTS AND WHAT THEY MEAN (some results may not be available)
AVAILABLE RESULTS AND
WHAT THEY MEAN
TEST
STRATEGY FOR GOOD HEALTH: REQUIRED TREATMENT/SERVICES/HEALTH ADVICE
TREATMENT
HEALTH ADVICE
HEALTH SERVICES NEEDED
MEDICAL HISTORY
FAMILY RELATIONSHIP
Does the patient care for someone else?
Yes  No 
Is the patient cared for by someone else?
Yes  No 
CURRENT ISSUES
RISK FACTORS
ALLERGIES/DRUG INTOLERANCE
CURRENT MEDICATIONS
(including prescription and over the counter and supplied by doctor without prescription)
RELEVENT FAMILY MEDICAL HISTORY
CONTINENCE
IDENTIFIED ISSUES
ACTION
IMMUNISATION STATUS - Consider INFLUENZA, TETANUS AND PNEUMOCOCCUS
ACTIVITIES OF DAILY LIFE
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IDENTIFIED ISSUES
ACTION
FALLS IN THE LAST 3 MONTHS
IDENTIFIED ISSUES
ACTION
IDENTIFIED ISSUES
ACTION
NUTRITION
ALCOHOL, TOBACCO AND OTHER SUBSTANCE USE
IDENTIFIED ISSUES
ACTION
IDENTIFIED ISSUES
ACTION
IDENTIFIED ISSUES
ACTION
IDENTIFIED ISSUES
ACTION
Alcohol:
Smoking:
Other:
Other:
HEARING LOSS
COGNITION
MOOD
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AVAILABILITY OF HELP
IDENTIFIED ISSUES
ACTION
CARING FOR ANOTHER PERSON
IDENTIFIED ISSUES
ACTION
MEDICAL EXAMINATION (MANDATORY)
BLOOD PRESSURE:
PULSE RATE AND RYTHM: Normal

Abnormal

IDENTIFIED ISSUES
Rate: _________
ACTION
WEIGHT:
HEIGHT:
BMI: ______ Waist Circumference (if indicated): ________
IDENTIFIED ISSUES
GUMS AND DENTITION:
Normal
ACTION

Abnormal
IDENTIFIED ISSUES
EAR AND HEARING: Otoscopy performed
IDENTIFIED ISSUES

ACTION

Whisper test performed

ACTION
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URINALYSIS Performed

IDENTIFIED ISSUES
TRICHIASIS
SKIN
ACTION

IDENTIFIED ISSUES
ACTION
IDENTIFIED ISSUES
ACTION

ENVIRONMENTAL AND LIVING CONDITIONS
IDENTIFIED ISSUES
VISUAL ACUITY
Normal

ACTION
Abnormal

IDENTIFIED ISSUES
ACTION
OTHER EXAMINATIONS CONSIDERED NECESSARY BY GP
EXAMINATION
IDENTIFIED PROBLEMS
ACTION
INVESTIGATIONS AS REQUIRED
INVESTIGATION
TESTS DONE
DATE TESTS ORDERED
ARRANGEMENTS (eg referral
details)
Fasting blood sugar
Lipids
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Pap Smear
STI
Mammography
Other
Other
ASSESSMENT OF PATIENT
(based on consideration of evidence from patient history, examination and results of any investigation)
EXISTING HEALTH ISSUES
IDENTIFIED RISK FACTORS
INTERVENTION ACTION
HEALTH ADVICE PROVIDED TO PATIENT OR PARENT/CARER
OTHER ACTION (if any)
ACTION TO BE TAKEN BY PATIENT
Next appointment with Doctor:
Date:
Next Health Assessment:
Date:
GP Signature: ______________________________
Date:
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