Health Assessment for an Aboriginal and Torres Strait Islander adult
(aged between 15 and 54 years) MBS item 715
Patient Name:
Date: Provider:
Informed consent has been obtained to prepare this plan.
Allergies
Medications, Foods and Insects.
Current health problems and risks
Family History
Prompt for Cancer, Heart Disease, Diabetes and musculoskeletal conditions.
Immunisation status
Smoking
Number of cigarettes, Frequency and Stage of Quitting(Not ready, Unsure: next 6 months, Ready: within 1 month)
Alcohol
Number of drinking days in a week, Number of Drinks in a day, Frequency of 6+ at once.
Exercise
Intensity of Activity, Frequency (should be most days) and Duration of activity.
Nutrition
Portions of fruit & vegetables per day, Frequency of Take out/fried food/pastries, Frequency of Soft drinks, cordials or juices.
Oral Health
Gums and dentition
Ear and hearing
History of hearing loss, perform Otoscopy and if indicated, whisper test.
Pap smears up to date
(Women only) Within the last 2 years
Last Mammography
(Women only if between 50-69yrs or Family Hx of Breast Ca)
Urinalysis (by dipstick)
(for proteinurea)
Confirm Medication list
Correct medication and doses recorded in patient file.
Screen for Depression
Over the past 2 weeks have you: Felt down, depressed or hopeless?
Felt little interest or pleasure in doing things?
Sexual and reproductive health
Family relationships and is the patient a carer?

Measurements

Weight:
Height:
Waist:
BMI:
Blood Pressure:
Pulse (rate & rythm):
AUSDRISK (Type 2 Diabetes Risk Tool)
1. Your age group / Score / 6. Are you on blood pressure medication? / Score
Under 35 years / 0 / No / 0
35-44 years / 2 / Yes / 2
45-54 years / 4 / 7. Do you smoke cigarettes/tobacco?
55-64 years / 6 / No / 0
65 years and over / 8 / Yes / 2
2. Your Gender / 8. How often do you eat vegetables or fruit?
Female / 0 / Everyday / 0
Male / 3 / Not everyday / 1
3a. Are you of Aboriginal or Torres Strait / 9. Do you do at least 2.5hrs of physical
Islander descent? / activity per week?
No / 0 / Yes / 0
Yes / 2 / No / 2
3b.Where where you born? / 10. Your waist measurement: Asian or ATSI
Australia / 0 / Men <90cm Women < 80cm / 0
Asia, Middle East, N. Africa, S. Europe / 2 / Men 90-100cm Women 80-90cm / 4
Other / 0 / Men 100cm+ Women 90cm+ / 7
4. Have any of your parents or siblings been
diagnosed with diabetes? / Total score
No / 0 / 5 or less = Low risk
6-11= Intermediate risk
12 or more = High risk
Yes / 3
5. Have you ever been found to have high
blood glucose (sugar)?
No / 0
Yes / 6
Arange Investigations
Fasting Blood Glucose Level
Fasting Cholesterol
Chlamydia and gonorrhoea (by urine or endocervical swab)

STRATEGY FOR GOOD HEALTH:

Health advice and treatment / Other Services Needed

ACTION TO BE TAKEN BY PATIENT

Next appointment with Doctor / Date:
Next Health Assessment (in 9 months) / Date: