Annual Health Assessment
For patients 75 and over. Aboriginal and Torres Strait Islander 55 and over. To be conducted by the patient's usual GP

Place of Assessment: 

GP details: 	Date: 

Patient's Name: 

DOB: 
	Allergies:
	
Smoking (frequency and number of cigs):
	Alcohol (frequency and number of drinks):

Family History:
	Medical History:
	
Is the patient a carer: 

Social History: 

Medications:

Medication issues/comments: 

Immunisations (Check Influenza, Pneumococcal & Tetanus are up to date):

Personal Nutrition Assessment
Do you eat at least 3 meals a day?:		
Do you eat fruit and vegetables most days? :		
Do you eat dairy most days?:		
Do you have 6 or more cups of fluid most days?:		
Are you free from problems with swallowing food, or with your teeth?:		
Are you free from health problems that affect the kind of food you eat?:		
Do you always have enough money to shop for food?:		
Weight remained stable in the past 6 months (not lost or gained 5+ Kg without intending to):		

Home Safety Assessment
Can you easily get up from seats and lounge chairs?:		
Can you easily get in and out of bed?:		
Can you switch on a light from your bed?:		
Are all (if any) floor mats firmly fixed and safe?:		
Is your bathroom slip resistant (matts or other protection)?:		
Can you easily manage with handles and lifting objects?:		
Can you easily walk up and down steps and stairs?:		

Personal Mobility Assessment
Can you bend and kneel?:		
Can you walk 100 metres easily?:		
Can you easily and safely bathe and dress yourself?:		

Falls in the past 3 months: 

Problems with memory:		

Mood Assessment:
1. Do you sometimes have difficulty sleeping?:		
2. In the last four weeks have you been troubled by problems such as feeling anxious, unhappy or with lack of motivation? :		

(If YES to question 2, perform GDS questionaire below) 

GDS questionaire 
1) Are you basically satisfied with your life? (yes= 0 / NO= 1) :		
2) Have you dropped many of your activities and interests? (YES= 1 / no= 0):		
3) Do you feel that your life is empty? (YES= 1 / no= 0):		
4) Do you often get bored? (YES= 1 / no= 0):		
5) Are you in good spirits most of the time? (yes= 0 / NO= 1):		
6) Are you afraid that something bad is going to happen to you? (YES= 1 / no= 0):		
7) Do you feel happy most of the time? (yes= 0 / NO= 1):		
8) Do you often feel helpless? (YES= 1 / no= 0):		
9) Do you prefer to stay at home, rather than going out and doing new things? (YES= 1 / no= 0):		
10) Do you feel you have more problems with memory than most? (YES= 1 / no= 0):		
11) Do you think it is wonderful to be alive now? (yes= 0 / NO= 1) :		
12) Do you feel pretty worthless the way you are now? (YES= 1 / no= 0):		
13) Do you feel full of energy? (yes= 0 / NO= 1):		
14) Do you feel that your situation is hopeless? (YES= 1 / no= 0):		
15) Do you think that most people are better off than you are? (YES= 1 / no= 0):		
Total score:		
Score Interpretation:		

Mini Mental State Examination
What is today's date? (1point):		
What is the year? (1point):		
What is the month? (1point):		
What day of the week is today? (1point):		
What season is it? (1point):		
What street are we on? (1point):		
What street/building number are we in?  (1point) :		
What suburb are we in? (1point):		
What state are we in?  (1point):		
What country are we in? (1point):		
Ask to repeat "ball","flag","tree" (1 point each correct. Max 3):		
Spell "world" backwards (1 point each letter in right place. Max 5):		
Recall 3 previous words  (1 point each: ball, flag tree. Max 3):		
Name 2 objects shown to patient (i.e. watch, pencil. 1point each. Max 2) :		
Repeat the following "no ifs, ands or buts" (1point):		
Follow a three stage command: "take the paper in your right hand, fold it in half and put it on the floor" (3 points):		
Repeat and obey the following CLOSE YOUR EYES (1 point):		
"Write a sentence"; must have noun, verb and be sensible. (1point):		
Draw 2 intersecting pentagons each side 1". Must have 10 angles and intersect.  (1point):		
Total score:		
Score interpretation:		

Patient currently drives: 

Examination/Observations:
Blood Pressure:		
Pulse rate:		
Pulse rhythmn:		

Social Support
- In the last four weeks was there anyone available to help you if you wanted or needed help? Paid/Unpaid-volunteer/Adequacy 	
	
- Access to emergency care:		
- Do you receive any community services? (Meals on Wheels/’Home Help’/etc)		
- Do you need any community services? (Transport, dressing, bathing, housework, shopping, meals, telephone, garden, other)		
- Have you had any problems with continence? (Bowels/Urine/Related to coughing or sneezing)		
- Do you experience any problems with your feet?		
Issues with oral health: 
Issues with vision:
Issues wit Hearing: 

Recommendations/Comments:
	
Consider GP MANAGEMENT PLAN due to Chronic Illness.:		
Consider a TEAM CARE ARRANGEMENT since the patient's chronic illness requires a multidisciplinary approach with at least 2 other providers.:		
Consider a HOME MEDICINE REVIEW BY A PHARMACIST:		
Consider a MENTAL HEALTH ASSESSMENT and MENTAL HEALTH PLAN:		
Discuss EMERGENCY PLAN/CONTACTS for dependents in case patient is unable to care for them:		
Discuss the need for an EMERGENCY MONITORING SYSTEM or "Medical alarm" to be installed so the patient is able to access timely care even when alone, in the event of an emergency.:		
Consider education/support to QUIT SMOKING.:		
Consider education/support to reduce or stop ALCOHOL CONSUMPTION:		
May be overdue for INFLUENZA VACCINATION.:		
May be overdue for PNEUMOCOCCUS VACCINATION:		
May be overdue for TETANUS booster.:		
Consider referral to CONTINENCE AUSTRALIA.:		
Consider referral to an OCCUPATIONAL THERAPIST or COUNCIL ASSESSMENT:		
Consider referral to a DIETITIAN.:		
Consider referral to PODIATRY.:		
Consider referral to OPTOMETRY.:		
Consider referral to AUDIOLOGY.:		
Consider referral to a MEMORY CLINIC.:		
Consider referral to physiotherapy/hydrotherapy.: