Preventive health assessment 75[+] years

PREVENTIVE HEALTH ASSESSMENT 75+ YEARS

CONSENT (yes/no)
Health assessment explanation given: 
Consent for health assessment obtained from patient:

LEGAL MATTERS (yes/no)
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 
[-] risks identified

GENERAL HEALTH RISK ASSESSMENT ("+" risk identified, "-" no risk)
[-] 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: 
-

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: 
-

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

Other considerations:
[-] Problems with bowel or urinary incontinence?
[-] Problems with feet?
Comments: 
-

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 eating without difficulty
[+] No loss or gain in weight > 5 kg in last 6 months
Comments: 
-

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: 
-

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: 
-

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: 
-

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: 
-

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

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

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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