Medicare Health Assessment for
Aboriginal and Torres Strait Islander People (MBS Item 715)

Adult Health Assessment (15-54)

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 for the health assessment found at www.health.gov.au/mbsonline. 

Patient’s Name …………………………………………..

Aboriginal                     Torres Strait Islander     

Works status ……………………………………………..	

Male        Female      	DOB:__/__/____ or Age:__

Aboriginal and Torres Strait Islander

Current contact details
Address ………………………………………………….
Phone  ……………………………………………………	
Alternative contact details  ……………………………..
Address  ………………………………………………….
Phone  ……………………………………………………	

Patient Consent

Explanation of health check given         Yes 

Patient consent for health check given  Yes 
Date consent was given:                          __/__/____	
Consent given for information to be collected by:

Aboriginal health worker                                        

Practice nurse

Other suitably qualified health professional 
	
Previous health assessment

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 
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	

RISK FACTORS IDENTIFIED AND DISCUSSED WITH PATIENT ………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	

Tests undertaken, results and what they mean (some results may not be available)	

TEST
	
AVAILABLE RESULTS AND WHAT THEY MEAN	

		

Strategy for good Health: Required Treatment/services/health advice	
TREATMENT	HEALTH ADVICE	HEALTH SERVICES NEEDED	

			
Action to be taken by patient
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	
Next appointment with doctor:
Next Health Assessment:	Date:  __/__/____
Date:  __/__/____	
GP:  Dr. ……………………………………….	GP’s signature  ……………….…………….	Date:  __/__/____	

MEDICAL HISTORY 
FAMILY RELATIONSHIP	

Does the patient care for someone else?	No		Yes

I

 

s the patient cared for by someone else?	No		Yes	

CURRENT ISSUES	
CURRENT RISK FACTORS	

		

ALLERGIES/DRUG INTOLERANCE
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	
CURRENT MEDICATIONS 
(including prescription and over the counter and supplied by doctor without prescription)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	
RELEVENT FAMILY MEDICAL HISTORY
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	
IMMUNISATION STATUS (referring to current age/sex schedule)	
TYPE	DATE	TYPE	DATE	

				

PHYSICAL ACTIVITY	

IDENTIFIED ISSUES	
ACTION	

		

NUTRITION	

IDENTIFIED ISSUES	
ACTION	

		

ALCOHOL, TOBACCO AND OTHER SUBSTANCE USE	

IDENTIFIED ISSUES	
ACTION	

		

HEARING LOSS	

IDENTIFIED ISSUES	
ACTION	

		

MOOD (depression and self harm risk)	

IDENTIFIED ISSUES	
ACTION	

		

SEXUAL AND REPRODUCTIVE HEALTH 	

IDENTIFIED ISSUES	
ACTION	

		

OTHER MEDICAL HISTORY AS INDICATED FOR PATIENT

VISUAL ACUITY (ask about clarity and comfort of vision at distance and near, recommended for over 40’s) 

IDENTIFIED ISSUES	
ACTION	

		

ENVIRONMENTAL AND LIVING CONDITIONS	

IDENTIFIED ISSUES	
ACTION	

		

Other history considered necessary by doctor or collector (eg work environment)	

IDENTIFIED ISSUES	
ACTION	

		

MEDICAL EXAMINATION 

BLOOD PRESSURE: …………………			PULSE RATE AND RHYTHM: 	Normal	Abnormal	

IDENTIFIED ISSUES	
ACTION	

		

WEIGHT: ……...	HEIGHT: ……...	BMI: ……...		Weight circumference (if indicated): ……...	

IDENTIFIED ISSUES	
ACTION	

		

GUMS AND DENTITION:     	normal          	abnormal 	

IDENTIFIED ISSUES	
ACTION	

		

EAR AND HEARING:   Otoscopy      	Whisper test (if indicated)	 	

IDENTIFIED ISSUES	
ACTION	

		

VISION:   Test near and distance visual acuity	 	

IDENTIFIED ISSUES	
ACTION	

		

URINALYSIS	

IDENTIFIED ISSUES	
ACTION	

		

OTHER MEDICAL EXAMINATION – AS INDICATED FOR PATIENT

TRICHIASIS           (Note: Examine those people who have grown up in remote communities or have a history of ‘sore or watery eye’)	

IDENTIFIED ISSUES	
ACTION	

		

SKIN         		

IDENTIFIED ISSUES	
ACTION	

		

Other examinations considered necessary by gp	

EXAMINATION
	
IDENTIFIED ISSUES	
ACTION	

			

iNVESTIGATIONS AS REQUIRED	
INVESTIGATION 		TESTS DONE 	TESTS ORDERED 	ARRANGEMENTS(eg referral details)

Fasting blood sugar				Date __/__/____			
Lipids							Date __/__/____

Pap Smear						Date __/__/____

STI							Date __/__/____

Mammography					Date __/__/____
Optometry                                                       Date __/__/____  	
Other………………………………………………………………………………………………………………………...
……………………………………………………………………………………………………………………………….	
ASSESSMENT OF PATIENT  

(based on consideration of evidence from patient history, examination and results of any investigation)	

EXISTING HEALTH ISSUES	
IDENTIFIED RISK FACTORS	

		

INTERVENTION ACTION 

HEALTH ADVICE PROVIDED TO PATIENT 
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
	
OTHER ACTION (if any)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
	
For information on this MBS item and its Explanatory Notes,
Visit the Department of Health and Ageing’s website at www.health.gov.au/mbsonline