Health Assessment work

sheet   - for <<Doctor:Name>>    Date:  <<Miscellaneous:Date>> 

Home p   Surgery  p   .. 

by nurse    nurse 1 p   or   nurse 2  p

( patient info sheet  http://www.nevdgp.org.au/info/careplans/healthassess_p_info.pdf  ) 

Patient Details:

<<Patient Demographics:Full Name>> , <<Patient Demographics:Age>>, <<Patient Demographics:Sex>>,  DOB: <<Patient Demographics:DOB>>

<<Patient Demographics:Address>>

, <<Patient Demographics:City>>, <<Patient Demographics:Postcode>> 

New Health Assessment  Yes

/ No  Repeat assessment:  Yes / No   (must be at least 12 months) 

Own Home: 

Yes / No  Supported Residential Care:  Yes / No 

Living with spouse: 

Yes / No     Friend/Relative: Yes / No      Alone:  Yes / No

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Health Screen      

*check medical director inserts are correct & complete * 

PAST HISTORY  

(Check for When or age of onset .. eg Hypertension diagnosed 1982)

Asthma: 

Yes / No    Diabetes: Yes / No   Cancer Bowel:  Yes / No    Cancer Prostate/Breast:  Yes / No         

Current information

<<Clinical Details:History

List>>

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FAMILY HISTORY 

( Details: whom and at what age ) also check for FH Hypertension, stroke, heart condition

Asthma: 

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