Preventive Health Assessment 75+ Years

#Preventive Health Assessment 75+ Years

CONSENT 
Health assessment explanation given: Yes
Consent for health assessment obtained from patient: Yes

LEGAL MATTERS 
Enduring power of attorney in place: ?
Advanced care directive in place: ?

CURRENT PATIENT CONCERNS

CARE ARRANGEMENTS 
Caring for another person:

Current care services:

HOME SAFETY

GENERAL HEALTH RISK ASSESSMENT (risks identified)
(-) Smoking/vaping history. 
(-) Alcohol use. 
(-) Physical activity - Exercise at least 30 minutes walking or equivalent 5 or more days per week.
(-) Sleep. 
(-) Dental health. 
(-) Significant active medical condition/s. 
(-) Regular medications. 
Comments if applicable:

Medical Support:
(-) Seen by any other doctor/specialist in the last six months?
(-) Regular health care from any other source (Allied/Pharmacist/Alternative/Other)?
Comments if applicable:

Activities of Daily Living:
(-) Arthritis: problems with handles, lifting, etc?
(-) Difficulty using stairs/steps?
(-) Falls in the last 12 months?
Comments if applicable:

Other Considerations:
(-) Problems with bowel or urinary incontinence?
(-) Problems with feet?
Comments if applicable:

Nutrition Assessment (daily intake):
(+) 4-7 serves vegetables/legumes
(+) 4-6 serves bread/cereals/rice/pasta
(+) 2-3 serves fruit
(+) 2-3 serves milk/yogurt/cheese
(+) 1-2 serves lean meat/fish/poultry/eggs/nuts (protein 1.0-1.2 g/kg/day)
(+) Consume six or more cups of fluid most days
(+) Swallowing and eat without difficulty
(+) No loss or gain in weight > 5 kg in last 6 months
Comments if applicable:

CANCER RISK ASSESSMENT (risks identified - screening arranged)
(-) Skin cancer

CARDIOVASCULAR RISK ASSESSMENT
(-) BP: ?
(-) Blood lipids. Every 5Y from 45Y; every 12M from 35Y if elevated risk. 
Comments if applicable:

IMMUNISATIONS (recommended)
(-) Influenza: Every year.
(-) Covid-19. 
(-) Pneumococcal: @ 70YY+ (13vPCV).
(-) Pneumococcal: ATSI @ 50Y+ (13vPCV then 23vPPV 2–12 months later, then 23vPPV at least 5Y later).
(-) Shingles: @ 50Y+ Shingrix (x2, 2-6 months apart).
(-) DTPa (Pertussis): Every 10Y.
(-) Other immunisations may be required for some medical conditions.
Comments (if applicable):

MENTAL HEALTH RISK ASSESSMENT
(-) Anxiety. 
(-) Bullying. 
(-) Child abuse history. 
(-) Cognitive decline. 
(-) Depression. 
(-) Gambling. 
(-) Intimate partner violence. 
(-) Loneliness. 
(-) Secure accommodation. 
(-) Personal safety. 
(-) Responsible for caring for someone else? 
Comments (if applicable):

METABOLIC HEALTH RISK ASSESSMENT
(-) Renal function (creatinine). Every 1-2Y if elevated risk from 30Y.

Height (cm): 
Weight (kg): 
BMI [20-25]: 
Waist measurement (cm): 
  [Asian or ATSI descent - women < 80 cm, men: less < 90 cm]
  [All others – women < 88 cm, men < than 102 cm]

Comments if applicable:

MISCELLANEOUS RISK ASSESSMENT (if indicated)
(-) Vision. 
(-) Hearing. 
(-) Pre-conception care. Opportunistically, child-bearing age.

(-) Family History Screening Questionnaire (FHSQ) Every 3Y. 
(-) Activity status questionnaire. If concerns about function. 
(-) Cardiovascular risk assessment. Every 5Y from 45-79Y. 
(-) Diabetes mellitus risk assessment. Every 5Y from 40-79Y. 
(-) Falls risk assessment. Every 12M 75Y+ (65Y+ if elevated risk); every 6M if history of falls. 
(-) Fracture / osteoporosis risk assessment.  All 50Y+, and post-menopausal women. 
Comments (if applicable):

RISK SUMMARY

PLAN INCLUDING REFERRALS (investigations requested)
(-) ECG: 
(-) Spirometry:

(-) FBE: 
(-) EUC / LFT: 
(-) Lipid Profile: 
(-) TFT: 
(-) B12 & Folate: 
(-) Iron Studies: 
(-) Vitamin D:

RESOURCE RECOMMENDATIONS
(-) Smoking: Quitline 137 848, [www.quit.org.au]
(-) Nutrition: The Australian Guide to Healthy Eating 1800 020 103, [www.healthyactive.gov.au] 
(-) Alcohol: National Alcohol and Other Drug Hotline 1800 250 015, [https://campaigns.health.gov.au/drughelp] 
(-) Physical activity: An active Way for Better Health, 1800 020 103, [www.healthyactive.gov.au] 
(-) Blood pressure: HeartLine 1300 362 787, [www.heartfoundation.org.au] 
(-) Osteoporosis: Osteoporosis Australia 8379 5711, [www.osteoporosis.org.au] 
(-) Cancer screening: [https://www.health.gov.au/health-topics/cancer/cancer-screening]

REFERRALS

REVIEW

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Notes

Medicare Australia Item Numbers:

701: <30 minutes
703: 30-44 minutes
705: 45-59 minutes
707: >60 minutes

Preventive Health Assessment 75+ Years

Notes

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