Medicare Health Assessment for Older Persons (75+)
 
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.   

Patient Details
Patient’s Name ………………………………..………………….…..	
Male  □  Female  □  DOB …../…../…..  or Age …...
Nationality ………………………………….……………
	
Current contact details
Address ……………………………………………….
Phone ………………………….………………………	
Carer’s name/s…………….…………………………...
Alternative contact details ..…………………………..
Address …………………….……………………….….
Phone ….…………………………………………….…
	
Consent – Patient and/or Carer
Explanation of health assessment given?   Yes    □ 
Consent for health assessment given?      Yes     □   
Consent given by?    Patient    □    Carer    □
Date consent was given …../…../…..
	Consent given for information to be collected by:
Nurse                                  Yes    □    No    □
Other health professional    Yes    □    No    □
If yes, please specify ..…...…………………………
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PATIENT’S OVERALL HEALTH STATUS
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HEALTH ISSUES IDENTIFIED AND DISCUSSED WITH PATIENT 
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Tests undertaken, results and what they mean (some results may not be available)

Note:  The assessment should not require diagnostic or pathology services unless the health assessment detects issues that necessitate clinically relevant diagnostic imaging or pathology services.

TEST
	AVAILABLE RESULTS AND WHAT THEY MEAN	

		

RECOMMENDED ACTION
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Action to be taken by patient and/or carer
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Next medical review due:	Date …../…../…..
Date …../…../…..	
Next Health Assessment due:		
GP    Dr. …………………………………….	GP’s signature ……………….…………….	Date …../…../…..	

PATIENT HISTORY

Government-provided or funded disability service
		
Previous presentations
		
Family relationships
		
Care arrangements

CURRENT ISSUES	
CURRENT RISK FACTORS

		

		

HEALTH ASSESSMENT 

		Check blood pressure	

	Identified HEALTH ISSUES	action	

			

		Check pulse rate and rhythm	

	Identified HEALTH ISSUES	action	

			

		Review medication	

	Identified HEALTH ISSUES	action	

			

		Assess continence	

	Identified HEALTH ISSUES	action	

			

		Assess psychological function including mood and cognition	

	Identified HEALTH ISSUES	action	

			

		Check immunisation status (Refer to the current Australian Standard Vaccination Schedule 	
		(NHMRC) for appropriate vaccination schedules).	

				Influenza	
 
				Tetanus	

				Pneumococcus	

	Identified HEALTH ISSUES	action	

			

		Assess patient’s physical function	

				Activities of daily living	
 
				Falls in the last 3 months	

	Identified HEALTH ISSUES	action	

			

		Assess patient’s social function	

				Availability/adequacy of paid and unpaid help	
 
				Whether the patient is responsible for caring for another person	

	Identified HEALTH ISSUES	action	

			

OPTIONAL COMPONENTS as relevant to the patient 

		Multi system review	

	Identified HEALTH ISSUES	action	

			

		Assess alcohol consumption	

	Identified HEALTH ISSUES	action	

			

		Assess level of exercise	

	Identified HEALTH ISSUES	action	

			

		Assess fitness to drive	

	Identified HEALTH ISSUES	action	

			

		Assess foot care	

	Identified HEALTH ISSUES	action	

			

		Assess hearing	

	Identified HEALTH ISSUES	action	

			

		Assess vision	

	Identified HEALTH ISSUES	action	

			

		Assess weight, height, body mass index	

	Identified HEALTH ISSUES	action	

			

		Assess sleeping patterns	

	Identified HEALTH ISSUES	action	

			

		Assess need for community services	

	Identified HEALTH ISSUES	action	

			

		Assess home safety	

	Identified HEALTH ISSUES	action	

			

		Assess mobility	

	Identified HEALTH ISSUES	action	

			
			
		Assess diet and nutritional status	

	Identified HEALTH ISSUES	action	

			

		Assess cardiovascular risk factors	

	Identified HEALTH ISSUES	action	

			

		Assess postural hypotension	

	Identified HEALTH ISSUES	action	

			

		Assess oral health	

	Identified HEALTH ISSUES	action	

			

		Assess smoking status	

	Identified HEALTH ISSUES	action