Health Check 	

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 below. The first 2 pages of this form can be used as a report of the health assessment. This check list must be read in conjunction with the explanatory notes for time-based items 701, 703, 705 or 707 (as set out in the Medicare Benefits Schedule).

	 ITEM  NUMBERS	X	Practice		 	
				1					
		 701(<30min)		 703(30-45 min) 		 705 (45-60min) 		 707(>60min)	
	
	Nurse time:		Doctor time:		Total time:			

Patient’s Name:  <<Patient Demographics:Full Name>>	
Gender: <<Patient Demographics:Sex>> 	DOB: <<Patient Demographics:DOB>>    Age: <<Patient Demographics:Age>> 
Current contact details 
Address: 	<<Patient Demographics:Full Address>>	
Phone:	<<Patient Demographics:Phone (Home)>>	
Carer’s name/s:		Phone: 		
Alternate carer’s name/s:		Phone: 		
Carer's contact detail:s		

Consent – Patient and/or Carer
Explanation of health assessment given:   ¨Yes	
Patient consent for health assessment given 	¨Yes
Date consent was given: 	Consent given for information to be collected by: 
Nurse 	¨Yes 	¨No
Other health professional 	¨Yes 	¨No
 - please specify: 	

Previous health check – Has the patient had a previous health assessment?  ¨ Yes   ¨ No         
Date of last health assessment (if known)		 Service provided by Dr.:		

PATIENT’S OVERALL HEALTH STATUS

HEALTH ISSUES IDENTIFIED AND DISCUSSED WITH PATIENT AND/OR CARER

TESTS UNDERTAKEN, RESULTS AND WHAT THEY MEAN (some results may not yet be available)
Note: The assessment should not include diagnostic or pathology services unless the health assessment detects issues that require clinically relevant diagnostic imaging or pathology services.
Test	Available results and what they mean	

		

RECOMMENDED INTERVENTION ACTION

ACTION TO BE TAKEN BY PATIENT AND/OR CARER

Next appointment with doctor: 	Date:		
Next Health Assessment:	Date:		

GP Name: <<Doctor:Name>>		 
GP’s signature ……………………………………………………………………..……	Date: <<Miscellaneous:Date>>
PATIENT HISTORY
Paediatrician		
Government-provided or funded disability service		
Previous presentations		
Family relationships		
Care arrangements		

Current problems	Current risk factors	

		

ALLERGIES / DRUG INTOLERANCE
<<Clinical Details:Allergies>>

HEALTH ASSESSMENT as relevant to the patient (mandatory from this point forward).
¨ Check dental health (including dentition)
Identified health issues	Action	

¨ Conduct aural examination (arrange formal audiometry every 5 years)
Identified health issues	Action	

¨ Assess ocular health (arrange ophthalmologist / optometrist review every 5 years)
Identified health issues	Action	

¨ Assess nutritional status and review growth and development 	weight:   		    height:   
Identified health issues	Action	

¨ Assess bowel and bladder function (particularly for incontinence and chronic constipation)
Identified health issues	Action	

¨ Assess medications (including non-prescription medicines taken by the patient, prescriptions from other doctors, medications prescribed but not taken, interactions, side effects and review of indications).
Identified health issues	Action	

¨ Check immunisation status (refer to the current Australian Standard Vaccination Schedule [NHMRC] for appropriate vaccination schedules).
¨ Influenza  	¨ Measles 	¨ Tetanus  	¨ Mumps
¨ Hepatitis A  	¨ Hepatitis B 	¨ Rubella (MMR) 	¨ Pneumococcal
Identified health issues	Action	

¨ Check exercise opportunities(aim for at least 30 minutes of moderate exercise per day)
Identified health issues	Action	

¨Check and review support provided for activities of daily living
Identified health issues	Action	

¨ Consider the need for breast examination, mammography, Papanicolaou smears, testicular examination, lipid measurement and prostate assessment 
Identified health issues	Action	

¨ Check for dysphagia and gastro-oesophageal disease, especially for patients with cerebral palsy, and arrange investigation/treatment as required.
Identified health issues	Action	

¨ Assess risk factors for osteoporosis and arrange investigation/treatment as required.
Identified health issues	Action	

¨ For patients diagnosed with epilepsy, review seizure control (including anticonvulsant drugs) and refer to neurologist as appropriate.
Identified health issues	Action	

¨ Screen for thyroid disease at least every two years (or yearly for patients with Down syndrome)
Identified health issues	Action	

¨ For patients without a definitive aetiological diagnosis, consider referral to a genetic clinic every 5 years. 
Identified health issues	Action	

¨ Assess or review treatment for comorbid mental health issues.
Identified health issues	Action	

¨ Consider timing of puberty and management of sexual development, sexual activity and reproductive health.
Identified health issues	Action	

¨ Consider any signs of physical, psychological or sexual abuse.
Identified health issues	Action	

HEALTH ASSESSMENT as relevant to the patient (Non-mandatory from this point forward).
The balance between the patient's health and physical, psychological and social function domains is a matter for professional judgement In relation to each patient. Practitioners should also consider the following:
Medical
¨ Consider follow-up consultations where required, eg. high blood pressure, likelihood of other health problems
¨ Assess pathology if continence problems are evident
Action	

Physical function
•	Consider the health impact of the patient's general skills levels and daily activities
•	Consider the need for a referral for a formal review of activities of daily living.
Action	

Psychological function
¨ Consider & investigate medical/ psychiatric causes where problems with cognition & skill decline are clinically suspected
¨ Consider depression where there is change in weight, sleep habit and escalation of behavioural problems
¨ Ensure there are systems in place to keep track of the patient’s current behavioural status
¨ Consider psychiatric disorders when changes in behaviour are evident.
Action	

Social function
¨ Assess suitability of the patient’s accommodation setting to provide best physical & psychological health outcomes
¨ Consider issues that relate to the care provided by the patient’s carer to meet the health related needs of the patient
Action	

¨ Other examinations as considered necessary by GP
Examination	Identified health issues	Action	

Involving the patient's carer or appropriate disability professionals
¨ Consider need for referrals such as accommodation, daily assistance, disability support services & psychologists.
Action