Health & Lifestyle AssessmentAberdeen City CHP – NHS Grampian

Medical Practice: / G.P. / Date:
Name: / Date of Birth:
Address:
Postcode: / Tel no:
Marital Status / Lives with:
Consent / Venue / Ethnic origin: / CHI No:
Next of Kin / Principle Carer if applicable

Yes No / Emergency contact if different from Next of Kin
Address / Name / Name
Telephone / Relationship / Address
Relationship / Carer at Screening
Yes No / Telephone
DOB if spouse / Physical Health / Relationship
Key holder
Yes No / Emotional Health / Key holder
Yes No
GP if Reg elsewhere / Requires Carer assessment

Yes No
Supportive
House Type / Home Care M T W Th F S S / Podiatry
Suitable for needs Yes No / Private Home Care M T W Th F S S / AHPs
Hazards / Wiltshire Foods M T W Th F S S / Care Manager Yes No
Heating / Day Centre / Clubs M T W Th F S S / Other
Cooking / DayHospital M T W Th F S S / Referral Yes No
Community Alarm Yes No / District Nurse M T W Th F S S / Attendance Allowance Yes No
Cold Alarm Yes No / Night Settling M T W Th F S S / Other Benefits
Smoke Alarm Yes No / CPN M T W Th F S S
Carbon Monoxide Alarm Yes No / Practice Nurse M T W Th F S S
Action
Activities Of Living
Communication:
Respiration: / Dentition:
Body Temp Control:
Vision: / Hearing:
Nutrition: / Feeding: / Fluids:
Personal care / Skin changes
Bathroom Facilities
Urinary Tract / Assessment (if required)
Bowel / Assessment (if required)
Mobility / Recent Falls
Psychological Status
Sleep
Social Contacts
Transport

Clinical Assessment

Past Medical History / Prescribed Medication
Match Drug Summary?
Yes No / OTC Medicines
Medication Review by GP/Pharmacist
Required?
Yes No
Compliance medication Aid
Yes No
Replenished by
Known Chronic Diseases (please tick all that apply)
CHD LVD Stroke/TIA Hypertension Diabetes COPD Epilepsy Hypothyroid

Cancer Mental Health Asthma If COPD/Asthma – Inhaler Technique? Good Bad

If Hypothyroid on GAFUR? Yes No
If Epileptic seizure frequency? ______Seizure free for more than 12 months? Yes No
MMSE or MSQ as appropriate. Do you feel it is necessary to undertake either of the above.
Yes No

Score MSQ Score MMSQ / Blood Pressure / / /
Standing if required:

Pulse: Regular Irregular Action
Re-check required Yes No

Urinalysis______MSSU Yes No
If diabetic – Microalbuminuria Test ______
Height Weight BMI
Flu Vac Discussed Yes No Home Surgery

Pneumovac discussed Yes No Date given
Allergies:
HEALTH ADVICE
Smoking
Current Smoker Ex smoker Never smoked
Smoking Cessation Advice Given Yes No
Alcohol
Within recommended limits Abstains
Above recommended limits Stopped
ADVICE GIVEN

Exercise Alcohol Dietary
Assessors Comments:

SSA Completed ? Yes No
Other Referral Form Completed Yes No If ‘Yes’ please detail:
Hospital Attendance in the past year:
Patients/Carers Concerns/Comments:
Assessor’s Signature Next Visit?

Referred to GP? Yes No GP Signature Date
GP Comments: