<<Miscellaneous:Practice Letterhead>>

45-49 Year Old Health Check 

Item 701	< 30 mins	
Item 703 	between 30 mins - 45 mins	
Item 705 	between 45 mins - 60 mins	
Item 707 	> 60 mins	

Date: <<Miscellaneous:Date>>

Patient Details: <<Patient Demographics:Full Details>>	Doctor: <<Doctor:Full Details>>	

Patient Eligibility
Patient is aged 45 - 49 years inclusive and is at risk of developing a chronic disease.  At least one risk factor must be identified. 
Patient is not an admitted patient of a hospital or day - hospital facility. 
Patient has not previously received the 45 year old health check.
This is a once only health check.
If you are unsure whether a patient has received the 45 year old health check phone Medicare Australia on 132 011.

LIFESTYLE RISK FACTORS:

Medical History:

Social History:
<<Clinical Details:Social History>>

Family History:
<<Clinical Details:Family History>>

Allergies
<<Clinical Details:Allergies>>

Smoking: Use Lifescripts smoking asessment and prescription
<<Clinical Details:Smoking>>
<<Clinical Details:Smoking Quitting Stage>>

Alcohol: Use Lifescripts alcohol asessment and prescription
<<Clinical Details:Alcohol>>

Physical Activity: Use Lifescripts pyshical activity asessment and prescription

MEDICATIONS:

Medications:
<<Clinical Details:Medication List>>

OTC Medications: 

Immunisation:
<<Clinical Details:Immunisation List>>

INVESTIGATIONS:

FBE:

EUC / LFT:

Lipid Profile:

FBG:

TFT:

PSA:

B12 & Folate:

Iron Studies:

Hormones:

Urinalysis:

Sexual and Reproductive Health Examination:

Pap Smear:

Prostate Check:

DRE:

Blood Pressure:           

Weight:     
Height:    
Waist Measurement:               
BMI:Use Lifescripts weight management asessment and prescription

EXAMINATIONS:

Eyes:

Hearing: 

ENT:

Skin Check:

ECG:

Spirometry:

HEALTH CHECK:

Medical Support
		
Have you seen any other doctor/specialist in the last six months?
	Y/N	
Do you get regular health care from any other source?
Allied/Pharmacist/Alternative/Other
	Y/N	
Activities of Daily Living
		
Arthritis: do you have problems with handles, lifting, etc?
	Y/N	
Are there stairs/steps that you have difficulty with?
	Y/N	
Have you had a fall in the last three months?
	Y/N	
Personal Nutrition Assessment
		
Do you eat three meals a day?
	Y/N	
Do you eat fruit and vegetables most days?
	Y/N	
Do you eat dairy most days?
	Y/N	
Do you have six or more cups of fluid most days?
	Y/N	
Do you have problems swallowing or eating?
	Y/N	
Have you lost or gained five kilos or more within the last six months ? (reasons)
	Y/N	
Other Considerations
	Y/N	
Have you had any problems with continence? 
Bowels/Urine/Related to coughing or sneezing
	Y/N	
Do you experience any problems with your feet?
	Y/N	
Are you responsible for caring for someone else?
	Y/N	
Psychological Assessment:
		
In the last four weeks have you been troubled by problems such as feeling anxious or very unhappy?
	Y/N	
Do you sometimes have difficulty sleeping?	
	Y/N	
Depression (K10)
	Y/N	

Recommendations:

HMR:								Y/N

721:								Y/N

723:								Y/N

2710:								Y/N

Bowel Screening:						Y/N

Cardio Assessment: 						Y/N

Advice Re: Siblings with FHx of disease:			Y/N

Patient Resources:

Testicular Self Examination
Understanding Vasectomy
Sexual Difficulties
Psychosocial Difficulties
Prostate Enlargement
Prostate Cancer
Testicular Cancer
Male Infertility
Cholesterol
Hypertension
Lifescripts
Asthma Action Plan