75 YEARS AND OLDER HEALTH ASSESSMENT	

An assessment of a patients health and physical, psychological and social function for the purpose of initiating preventative health care and/or medical interventions as appropriate. 
May be claimed once every twelve months by an eligible patient. 

Indicate MBS Item Number
	Item No 701
< 30 minutes		Item No 703
30-45 Minutes		Item No 705
45-60 Minutes		Item No 707
> 60 Minutes	

PATIENT DETAILS
Name: <PtName>	DOB: <PtDoB>	
Gender: <PtSex>	ATSI: <Does the patient identify as ATSI>	
Address: <PtStreet> <PtCity> <PtPostcode>	
Telephone:	(Home) <PtPhoneH>	(Work) <PtPhoneWk>	(Mobile) <PtPhoneMob>	
Interpreter Required: <Interpreter required>	If Yes, Language: <   If Yes, language>	

ALTERNATIVE CONTACT DETAILS
Name: <Alt contact name>	Address: <Alt contact address>	Phone: <Alt contact phone>	

PATIENT CONSENT
Explanation of health check given: <Explanation of health check given>
Patient consent for health check given: <Patient Consent was given>
Date consent was given: 
<Date consent was given>
Copy of Health Assessment Offered to Patient and/or Carer: <Copy of Health Assessment Offered to Patient>	Consent given for information to be collected by 
q Practice Nurse
)
Consent to share/refer to other health providers: <Consent to share/refer info to other health providers> 
Comments:	

BACKGROUND INFORMATION
Patient says current health is: 
<Patient says current health is> 	Concerns:
	
Have you seen any other Doctor/GP/Specialist in the last 6 months? 

<Dr GP Specialist in last 6 months?>	Name and Details:

<Dr GP Specialist name and details>	

MEDICAL HISTORY
<PMHActive>

PHYSICAL ASSESSMENT
Height
Weight
BMI
Heart Rate		
Blood pressure		

RELEVANT FAMILY HISTORY
<FamilyHx>

MEDICATIONS 
<CurrentRx>
Manages own medicines?	q Yes	q No	
Uses Dosette?	q Yes	q No	
Compliance issues?	q Yes	q No	
Polypharmacy (>5 meds)?	q Yes	q No	
Checked expiry dates -                    Any issues?	q Yes	q No	
Recommended Home Medicines Review?	q Yes	q No	
			
Comments:			

IMMUNISATION STATUS <Imm>

ALLERGIES 
<Reactions>

ALCOHOL
Within healthy guidelines?	q Yes	q No	
	
Comments:

SMOKING
If smoker, plan to Quit?
If smoker, consider spirometry	q Yes	q No	•		
Comments:

SOCIAL HISTORY
Who do you live with?      
Concerns?			
Do you care for someone else?   If yes, how many hours per day?	q Yes	q No	
Are you cared for by someone else?
Concerns?	q Yes	q No	
What is the current Housing situation?
Concerns?			
Stressful Life Events
Comments:			
Do you have any financial issues or concerns? If yes, please identify	q Yes	q No	
Do you have any issues or concerns regarding transport?
If yes, please identify	q Yes	q No	
During the last 4 weeks, was someone available to help if needed /wanted help? For example if you: felt very nervous, lonely or sad/became sick and had to stay in bed/needed someone to talk to/needed help with daily chores/needed help just taking care of yourself?
Comments:
	q Yes	q No	
Do you have any additional paid help/unpaid help?
Details:	q Yes	q No	
Do you regularly participate in religious or other social activity?	q Yes	q No	
Do you meet regularly with friends or family?  How often?	q Yes	q No	
Do you need additional support/community services?
eg.dressing/bathing/housework/shopping/meals/telephone/garden
/other? If yes, please identify	q Yes	q No	
Have you been assessed by the Aged Care Assessment Team (ACAT)?
If yes, date of the assessment: <ACAT Assessment date>
What level of care was deemed appropriate for you at this time?
          Independent Living / Low Care / High Care
If no, would you like to be assessed?	q Yes

q Yes	q No

q No	

LEGAL ISSUES
			Notes	
Have you made any arrangements for enduring power of attorney should it become necessary? Comments:	q Yes	q No		
Have you made any arrangements for guardianship should it become necessary?
Comments:	q Yes	q No		
If you were to become terminally ill, have you considered the level of medical intervention you would prefer?
Comments:	q Yes	q No		
If you drive, have you been assessed for fitness to drive? Comments:	q Yes	q No		
Referrals/required actions:

OTHER HEALTH CARE PROVIDERS / COMMUNITY SERVICES
•	
•	
•		q Yes	q No	
Do you have ambulance cover?	q Yes	q No	
Referrals/required actions/comments:

MOBILITY / ACTIVITY
			Notes	
Are you physically active? 
Any difficulty?	q Yes	q No		
Do you use a walking aid, such as a walking stick, frame, wheelchair or motorised scooter?
Comments:	q Yes	q No	
	
Do you need to hold on to furniture when moving around?	q Yes	q No	      	
Do you have difficulty bending, kneeling or stooping?	q Yes	q No		
Can you carry objects e.g. meals easily and safely from the kitchen to your dining area?	q Yes	q No		
Are you able to look after the inside/outside of the house?  Comments:
	q Yes	q No		
Do you need help to dress?	q Yes	q No		
Do you have difficulty gripping utensils or handrails?	q Yes	q No		
Referrals/required actions:

HOME SAFETY & RISK FOR FALLS / INJURIES
			Notes	
Have you had a fall/near fall in the past 6 months?
If yes, how many?
Were you hurt as a result of any of these falls?
What were you doing when you fell?

Did you need assistance to get up from the floor?	q Yes

q Yes

q Yes	q No

q No

q No		
Can you:
•	get up from your lounge chair easily?
•	get in and out of bed?
•	switch a light on from your bed?
•	get on and off toilet easily?
•	get in/out of the shower/bath?
Describe any difficulties

	q Yes
q Yes
q Yes
q Yes
q Yes	q No
q No
q No
q No
q No		
Do you have any steps/stairs in your home?
Any difficulties?	q Yes	q No		
Do you need any safety equipment? e.g. walking aid/home modifications.grab rails fitted
Comments:
	q Yes	q No		
Is the house free of obvious slipping and/or tripping hazards? e.g. floor mats that slip	q Yes	q No		
Do you have smoke detectors fitted to your home?
When was the battery last changed:	q Yes	q No		
Referrals/required actions:

				

NUTRITION
			Notes	
Recent reported weight loss
(>7.5% in past 3 months - have your clothes become loose by a size or belt notches?)	
q Yes	
q No		
Difficulty with food intake (loss of appetite, nausea, swallowing or digestive problems)?

Recent acute illness, stress, dementia or depression impacting on food intake?
Comments:

	q Yes	q No		
Ability to shop/prepare/cook own meals. Difficulties?
Comments:

	q Yes	q No		
Do you drink 6-8 cups of fluids most days?	q Yes	q No		
Do you eat alone?  How often?
Comments:

	q Yes	q No		
Referrals/required actions:

ORAL HEALTH 
			Notes	
Do you have any of your own natural teeth?	q Yes	q No		
Any issues/recommendations:

	

VISION
Left        /6            Right        /6            Both        /6
Acuity (with glasses)				
Do you have problems with your eyesight?
Describe	q Yes	q No		
Are you able to read newspapers and books, and watch TV? Any concerns?	q Yes	q No		
Referrals/required actions:

HEARING
			Notes	
a: Whisper Test
b. Check ear canals
c. Hearing Aid				
Do you have problems with hearing?
If yes, describe	q Yes	q No		
Are you able to hear and use the telephone?	q Yes	q No		
Referrals/required actions/comments:

PERSONAL WELLBEING ASSESSMENT & SAFETY
			Notes	
During the last 4 weeks, have you been feeling emotional such as anxious, depressed, irritable or downhearted?
If yes, please describe
	q Yes	q No		
Do you have difficulty sleeping?
If yes, please describe
	q Yes	q No		
If patient alone ask:
Has a friend or family member made you feel afraid?
Has a friend or family member hurt you physically?
Comments

:	
q Yes

q Yes	
q No

q No		
Referrals/required actions:

COGNITION
			Services/Providers	
Any problems with memory, thinking, planning, motivation?  Comments:`	q Yes	q No	•	Consider Geriatrician review	
Referrals/required actions:

MENTAL STATUS SCREEN (If indicated)
see attached			Score	

CONTINENCE
			Notes	
Do you ever wet yourself?
If yes, is this related to coughing or sneezing?	q Yes
q Yes	q No
q No		
Do you have any trouble passing urine?
If yes, please describe	q Yes	q No		
How often do you go to the toilet at night?				
Do you ever lose control of your bowels?	q Yes	q No		
Have you had a recent change of bowel habit/blood in your motion?
If yes, please describe	q Yes	q No		
Referrals/required actions:

SKIN AND FEET
			Services/Providers	
Peripheral pulses and venous return				
Do you have problems with one or both feet?	q Yes	q No		
Are you able to manage your foot and toenail care?	q Yes	q No		
Skin integrity: Do you have any areas where your skin is itchy, red, sore, flaky?	q Yes	q No		
Is your skin easily bruised, torn, irritated?	q Yes	q No		
Referrals/required actions:

REPRODUCTIVE & SEXUAL HEALTH
			Notes	
				
When was your last mammogram?

Do you perform breast self examination?

q Yes	

q No		
When was your last prostate check?				
Any other topic patient wants to talk about?		
		
Referrals/required actions:

MEDICAL EXAMINATION
	Action/Referral	
Cardiovascular		
Respiratory		
Neurological		
Gastrointestinal		
Other as appropriate

INVESTIGATIONS
	Action/Referral	
BGL		
Urinalysis		
Bone density		
Other as appropriate

SUMMARY OF HEALTH ASSESSMENT

<PtName> / <PtDoB>
Based on consideration of evidence from patient history, examinations, lifestyle risk factors and results of any investigation
Patients overall health	
Existing health problems	
Identified Risk Factors	
Health advice provided to patient/carer	

PERSONAL GOALS
Identified personal goals and plan of action

INTERVENTION
		Action/Referral	
GPMP	MBS Item No 721		
TCA	MBS Item No 723		
Mental Health Plan	MBS Item No 2710		
Home Medicines Review	MBS Item No 900		
Case Conference	MBS Item Nos 735-758		
Other

GP DETAILS
Details of person completing this assessment:
Name: <DrName>
Practice: <Practice>
Phone: <DrPhone>                      Fax: <DrFax>
Provider No: <DrProviderNo>
Signature:

Date: <Date>	

Health Assessment filed in Medical Records - Date 
<Health Assessment filed in Medical Records Date>
Review for next Health Assessment - Date <Review for next Health Assessment Date>