OlderPersonover75yearsMay10 000 by MfT85YYG

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									                     Annual Health Assessment
                          For patients 75 and over
                  To be conducted by the patient's usual GP
Item numbers        Item 701    Item 703              Item 705      Item 707   
GP details:                                     Date:

Signature:___________________________________

Patient's Name:

Past History:


Allergies:


Smoking:

Alcohol:

Social History:

Family History:

Hearing:


Vision:


Progress notes:
<<Summary:Progress Note (Current)>>

Medications:

Side effects
Interactions
Suggested changes
Webster pack         Yes No
Carer gives          Yes No
medications

Immunisations:
Investigations
HEALTH ASSESSMENT
Examination/Observations:
Weight:
Blood Pressure:
Pulse:
Rhythmn:
Ears:
Other:
Medical Support
Have you seen any other doctor/specialist in the last six   Yes No
months?
Do you get regular health care from any other source?
 Allied/Pharmacist/Alternative/Other                       Yes No
Social Support
In the last four weeks was there anyone available to help
you if you wanted or needed help?
 Paid/Unpaid-volunteer/Adequacy                            Yes No
Are you responsible for caring for someone else?            Yes No
Do you receive any community services?                      Yes No
 Meals on Wheels/’Home Help’/etc
Do you need any community services?                         Yes No
 Transport/dressing/bathing/housework/shopping/meal
  s/telephone/garden/other
Personal Wellbeing Assessment
In the last four weeks have you been troubled by            Yes No
problems such as feeling anxious or very unhappy?
Do you sometimes have difficulty sleeping?                  Yes No
Have you had any problems with continence?                  Yes No
 Bowels/Urine/Related to coughing or sneezing
Do you experience any problems with your feet?              Yes No
Home Safety Assessment
Can you easily get up from seats and lounge chairs?         Yes No
Can you easily get in and out of bed?                       Yes No
Can you reach and switch on a light from your bed?          Yes No
Do you have floor mats and are they fixed safely?           Yes No
Do you use slip resistant mats in the bathroom?             Yes No
Arthritis: do you have problems with handles, lifting, etc? Yes No
Are there stairs/steps that you have difficulty with?       Yes No
Do you need grab rails in your                              Yes No
 Bathroom/toilet/entry/stairs/steps/other?
Personal Mobility Assessment
Can you bend and kneel?                                    Yes No
Can you climb a full flight of stairs?                     Yes No
Can you walk a hundred metres?                             Yes No
Can you bath and dress yourself?                           Yes No
Have you had a fall in the last three months?              Yes No
Personal Nutrition Assessment
Do you eat three meals a day?                              Yes No
Do you eat fruit and vegetables most days?                 Yes No
Do you eat dairy most days?                                Yes No
Do you have six or more 8 cups of fluid most days?         Yes No
Do you have problems swallowing, eating or your teeth? Yes No
Do you have any health problems that affect the kind of    Yes No
food you eat?
Do you always have enough money for food?                  Yes No
Have you lost or gained five kilos or more within the last Yes No
six months and if so for what reasons?
Psychological Assessment:
Memory
Folstein MMSE                                     /30
Depression                               Yes No
Fitness for driving:

Recommendations:

Patient agrees to formulation of the Health Assessment and to sharing of information
contained therein with other services / providers involved in his/her care. Patient has been
given the opportunity to withhold medical or other information from others.

Copy provided to               Patient     □            Carer   □       Other Providers
□
Date………………………..
Patient Signature……………………………………….

GP Signature…………………………………………….….…………...

								
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