COMPREHENSIVE MEDICAL ASSESSMENT

	 ITEM  NUMBERS	X	Aged Care Home		 	
									
		 701(<30min)		 703(30-45 min) 		 705 (45-60min) 		 707(>60min)	
	
	Nurse time:		Doctor time:		Total time:			

Date completed: <<Date CMA completed>>

Resident Name:  <<Patient Demographics:Full Name>>   DOB:  <<Patient Demographics:DOB>>

Aged Care Home: <<Patient Demographics:Full Address>> PH: <<Patient Demographics:Phone (Home)>>   Fax: 

Treating GP:  <<Doctor:Name>>  Tel:  <<Doctor:Phone>>  Fax: <<Doctor:Fax>>

Next of Kin:  <<Next of kin>>		PH:  <<Next of kin phone no.>>

Advance Care Directive:		<<Advance Care Directive>>	
Enduring Power of Attorney:	 <<Enduring Medical Power of Attorney>>	
Details:		
										
PAST MEDICAL HISTORY

CURRENT MEDICATION  
<<Clinical Details:Medication List>>
ALLERGIES or ADVERSE DRUG REACTION	

IMMUNISATION STATUS
<<Clinical Details:Immunisation List>>

Medical 	Examination	Identified Issues	
Cardiovascular
	BP:         
Pulse:
Other:		
Respiratory	Chest  
		
Gastro-Intestinal
		Abdomen:  

Weight: 
Height: 
BMI:

Oral Health: 
Nutrition: 		
CNS/Musculoskeletal	
		
Hearing
		p	Normal
p	Impaired
p	Wears Aids	 	

Vision
		p	Normal
p	Impaired

Aided: 	R	L 

Unaided : 	R	L 		
Skin	Ulcers
p Yes
p No

Other:		
Feet	Pulses
sensation		
Other
(if relevant)	eg. breasts, PR, vaginal examination		
Psychological and behavioural	p Normal
p    Problems		
Cognition
(see Minimental examination attached)	p Normal
p Impaired
MMSE       /30 		

Pain	Acute     pYes pNo
Chronic  pYes pNo		
Sleep	p Adequate
p Inadequate		
Continence
	
Urinary Incontinence:
pYes pNo

Faecal Incontinence:
pYes pNo

Urinalysis – if indicated
Protein: 
Blood:
Glucose:  		
Physical function	Mobility
p independent
p aid
p assistance
p 	not mobile  

Recent Falls
pYes pNo		
ADLs
Assistance required			
Smoking status
	<<Clinical Details:Smoking>>		
Alcohol status	<<Clinical Details:Alcohol>>		

SUMMARY
PROBLEMS IDENTIFIED    	ACTION REQUIRED    	

		

		

This patient needs:	Care Plan contribution	p
				Case Conference		p
				Family Meeting		p
				RMMR			p

GP Signature  					 Date  				

GP Name: <<Doctor:Name>>
RECENT INVESTIGATIONS
<<Summary:Investigation Results (Selected)>>