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

Older Person (55+) Health Assessment

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 a doctor without prescription)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	
RELEVENT FAMILY MEDICAL HISTORY
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	

CONTINENCE	

IDENTIFIED ISSUES	
ACTION	

		

IMMUNISATION STATUS – INFLUENZA, TETANUS AND PNEUMOCOCCUS 
(referring to current age/sex schedule)	
TYPE	DATE	TYPE	DATE	

				

ACTIVITIES OF DAILY LIFE	

IDENTIFIED ISSUES	
ACTION	

		

FALLS IN THE LAST 3 MONTHS	

IDENTIFIED ISSUES	
ACTION	

		

NUTRITION	

IDENTIFIED ISSUES	
ACTION	

		

ALCOHOL, TOBACCO AND OTHER SUBSTANCE USE	

IDENTIFIED ISSUES	
ACTION	

		

HEARING LOSS	

IDENTIFIED ISSUES	
ACTION	

		

VISUAL ACUITY (ask about clarity and comfort of vision at distance and near)

IDENTIFIED ISSUES	
ACTION	

		

COGNITION	

IDENTIFIED ISSUES	
ACTION	

		

MOOD 	

IDENTIFIED ISSUES	
ACTION	

		

AVAILABILITY OF HELP	

IDENTIFIED ISSUES	
ACTION	

		

CARING FOR ANOTHER PERSON	

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 	

ACTION	

		

EAR AND HEARING:   Otoscopy      	Whisper test (if indicated)	 	

IDENTIFIED ISSUES	
ACTION	

		

URINALYSIS        	

IDENTIFIED ISSUES	
ACTION	

		

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	

ENVIRONMENTAL AND LIVING CONDITIONS 	

IDENTIFIED ISSUES	
ACTION	

		

VISUAL ACUITY		Normal		Abnormal         (Test near and distance visual acuity)

IDENTIFIED ISSUES	
ACTION	

		

Other examinations considered necessary by gp

EXAMINATION
	
IDENTIFIED PROBLEMS	
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