Medicare Health Assessment for People Aged 45 to 49 Years Who are at Risk of Developing Chronic Disease 

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 in the Explanatory Notes at www.health.gov.au/mbsonline

Patient’s Name …………………………………………..

Male        Female                    DOB:  …../…../….. or

Age: ………………. (45-49 Inclusive)	

Country of Birth: …………………………………………
	
Patient’s Occupation: ………………………………..
	
Consent – Patient

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      

Type of assessment: ……………………………………	

Date of last health assessment (if known)…../…../…..

Service provided by Dr. .………………………………..	

HEALTH ASSESSMENT SUMMARY	

PATIENT’S OVERALL HEALTH STATUS
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HEALTH ISSUES IDENTIFIED AND DISCUSSED WITH PATIENT
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Tests undertaken as indicated, results and what they mean 
	
TEST	RESULTS AND WHAT THEY MEAN	

		

RECOMMENDED INTERVENTION 
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Next appointment with doctor:	Date:  …../…../…..	

GP:  Dr. ……………………………………….	
GP’s signature  ……………….………… 

Date:  …../…../…..…. 		

Components of the Health Assessment 

Information Collection 
Patient history
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CURRENT HEALTH ISSUES	CURRENT RISK FACTORS	

		

	
Family history of chronic disease
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Other relevant family history
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Risk Factor Assessment of the Patient
Note: A chronic medical condition is one that has been, or is likely to be, present for 6 months or longer.

		Asthma	

	RISK FACTORS	action	

			

		Cancer	

	RISK FACTORS	action	

			

		Cardiovascular illness	

	RISK FACTORS	action	

			

		Diabetes mellitus	

	RISK FACTORS	action	

			

		Mental health conditions (depression and self harm risk)	

	RISK FACTORS	action	

			

		Arthritis	

	RISK FACTORS	action	

			

		Musculoskeletal conditions (including osteoporosis)	

	RISK FACTORS	action	

			

		Other	

	RISK FACTORS	action	

			

Lifestyle Risk Factors

		Smoking	

	RISK FACTORS	action	

			

		Nutrition	

	RISK FACTORS	action	

			

		Alcohol and other substance misuse	

	RISK FACTORS	action	

			

		Physical inactivity	

	RISK FACTORS	action	

			

		Moods	

	RISK FACTORS	action	

			

Biomedical Risk Factors

		Blood pressure	

Blood Pressure: …………………. Pulse Rate and Rhythm:   Normal               Abnormal	

	RISK FACTORS	action	

			

		Body weight	

		Waist circumference (if indicated): ……………………………...	
			
		Weight: ……………  Height: ………………  BMI: ………………	

	RISK FACTORS	action	

			

		High cholesterol	

	RISK FACTORS	action	

			

		Impaired glucose metabolism	

	RISK FACTORS	action	

			

		Urinalysis	

	RISK FACTORS	action	

			

		Other examinations considered necessary by GP	

	RISK FACTORS	action	

			

Investigations if clinically indicated 
Investigation	Tests Done	Tests Ordered	Arrangements (e.g. referrals)	
Fasting blood sugar	□	Date: . . . / .. . . /. . . . . 
		
Lipids	□	Date: . . . / .. . . /. . . . . 		
Pap Smear	□	Date: . . . / .. . . /. . . . . 		
Mammography	□	Date: . . . / .. . . /. . . . . 		
Testicular Examination	□	Date: . . . / .. . . /. . . . . 		
Prostate Assessment	□	Date: . . . / .. . . /. . . . . 		
Other: 

Advice and Information to the Patient (including strategies to achieve lifestyle and behaviour changes)

Risk factors identified and discussed with patient
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Action to be taken by the patient
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Other action (if any)
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