Over 75 Health Assessment

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's Name:
<<Patient Demographics:Full Details>>	GP details:
<<Doctor:Full Details>>	

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>>

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

Nutrition: Use Lifescripts nutrition asessment and prescription

Physical Activity: Use Lifescripts pyshical activity asessment and prescription

Hearing:

Vision:

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

Medications:
<<Clinical Details:Medication List>>

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

Immunisations:
<<Clinical Details:Immunisation List>>

Investigations
<<Summary:Investigation Results (Selected)>>

Health Assessment

Examination/Observations:
Weight:	<<Clinical Details:Measurements>>	
Height	<<Clinical Details:Measurements>>	
Blood Pressure:	<<Clinical Details:Measurements>>	
Pulse:	<<Clinical Details:Measurements>>	
Rhythmn:		
Ears:		
Other:		

Medical Support
Have you seen any other doctor/specialist in the last six months?	
Yes No	
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?
•	Meals on Wheels/’Home Help’/etc	Yes No	
Do you need any community services?
•	Transport/dressing/bathing/housework/shopping/meals/telephone/garden/other	Yes No	
Personal Wellbeing Assessment
In the last four weeks have you been troubled by problems such as feeling anxious or very unhappy?	
Yes No	
Do you sometimes have difficulty sleeping?		Yes No  	
Have you had any problems with continence? 
•	Bowels/Urine/Related to coughing or sneezing	Yes No	
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
•	Bathroom/toilet/entry/stairs/steps/other?	Yes No	
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 food you eat?	Yes No	
Do you always have enough money for food?	Yes No	
Have you lost or gained five kilos or more within the last six months and if so for what reasons?	Yes No	
Adequate intake of Calcium and Vitamin D	Yes No	
Psychological Assessment:
Memory		

Mini Mental State Examination

Task	Points	
1.	Ask the patient what is the year, season, date, day of week and month
     One point for each correct answer
		
2.	Ask the patient: “where are we?” prompt for country, state, town, building floor/room
     One point for each correct answer
		
3.	Name 3 common objects slowly and clearly, e.g. apple, table, penny. Ask the patient to repeat them.
     One point for each item correctly repeated
		
4.	Ask the patient to count backwards from 100 by 7. Stop after 5 answers (alternatively, ask them to spell ‘world’ backwards) 
          One point for each correct answer (or letter)
		
5.	Ask the patient to recall the objects learned earlier (apple, table, penny)
     One point for each item correctly remembered.
		
6.	Point to your watch and ask the patient ‘what is this?’ Repeat with a pencil.
          One point for each correct answer
		
7.	Ask the patient to repeat this phrase after you: ‘no ifs, ands or buts’
     Give one point if successful on first try
		
8.	Give the patient a piece of paper and say ‘take this paper right hand, fold it in half and put it on the floor’
     One point for each correct action
		
9.	Show the patient a piece of paper with “CLOSE YOUR EYES” printed on it
     One point if the patient closes their eyes
		
10.	Ask the patient to write a sentence.
One point if the sentence has a subject, a verb and makes                                                                               sense
		
11.	Ask the patient to copy a pair of intersecting pentagons onto a piece of paper. 
One point if the figure has 10 corners and 2 intersecting lines. 		
TOTAL

	

INTERPRETING SCORE	0 – 17
Marked cognitive impairment, very likely to be dementia	18 – 23
Moderate cognitive impairment, quite possibly dementia	24 – 30
Normal range. Interpretation depends on previous level of education, language/culture.	

Geriatric Depression Scale (GDS)
MOOD SCALE
Choose the best answer for how you have felt over the past week:

Are you basically satisfied with your life? 					YES / NO
Have you dropped many of your activities and interests? 		YES / NO
12.	Do you feel that your life is empty?				YES / NO
13.	Do you often get bored? 						YES / NO
14.	Are you in good spirits most of the time? 				YES / NO
15.	Are you afraid that something bad is going to happen to you? 	YES / NO
16.	Do you feel happy most of the time? 				YES / NO
17.	Do you often feel helpless? 						YES / NO
18.	Do you prefer to stay at home, rather than going out and doing new things? YES / NO
19.	Do you feel you have more problems with memory than most? 	YES / NO
20.	Do you think it is wonderful to be alive now?			YES / NO
21.	Do you feel pretty worthless the way you are now? 		YES / NO
22.	Do you feel full of energy? 						YES / NO
23.	Do you feel that your situation is hopeless? 			YES / NO
24.	Do you think that most people are better off than you are? 	YES / NO

Answers in bold score 1 point. GDS-15 Score _________
A GDS-15 score of 5-9 indicates possible depression; above 9 usually indicates depression

The GDS is a screening tool and not a diagnosis. Although differing sensitivities and
specificities have been obtained across studies, for clinical purposes a score of 6 points or
more is suggestive of depression and should warrant a thorough assessment.

Fitness for driving:

Recommendations:

GP Signature: ________________________________