Medicare Health Assessment for Aboriginal and Torres Strait Islander People



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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
Is 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


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