Medicare Health Assessment for
Aboriginal and Torres Strait Islander People (MBS Item 715) 

Child Health Assessment (0-14)

Use of a specific form to record the results of the health assessment is not mandatory but the health assessment should cover the matters listed in the Explanatory Notes at www.health.gov.au/mbsonline. 

Patient’s Name …………………………………………..

Aboriginal                     Torres Strait Islander     	

Male        Female             DOB: __/__/____ or Age:__

Aboriginal and Torres Strait Islander
	
Current contact details

Address  ………………………………………………….
Phone  ……………………………………………………	Parent or Carer’s name/s  …………………………..….
Alternative contact details  ……………………………..
Address  ………………………………………………….
Phone  ……………………………………………………
	
Consent – Patient or Parent/Carer

Explanation of health check given         Yes 

Patient consent for health check given  Yes 
Date consent was given:                          __/__/____	Consent given for information to be collected by:

Aboriginal and Torres Strait Islander 
health practitioner

Practice nurse

Other suitably qualified health professional    	

Previous health assessment
Has the patient had a previous health assessment?

Yes               No      	

Date of last health assessment (if known) __/__/____
Service provided by Dr. .………………………………..	

PATIENT’S OVERALL HEALTH 
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	

RISK FACTORS IDENTIFIED AND DISCUSSED WITH PATIENT OR PARENT/CARER
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	

Tests undertaken, results and what they mean (some results may not be available)	

TEST	
AVAILABLE RESULTS AND WHAT THEY MEAN	

		

Strategy for good Health: Required Treatment/services/health advice	
TREATMENT	HEALTH ADVICE	HEALTH SERVICES NEEDED	

			

Action to be taken by PARENT/carer
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	
Next appointment with doctor:	Date:  …../…../…..
Date:  …../…../…..	
Next Health Assessment:		
GP:  Dr. ……………………………………….	GP’s signature  ……………….…………….	Date:  …../…../…..	

MEDICAL HISTORY as appropriate for age of patient

BACKGROUND INFORMATION – Child health record reviewed     Yes 
Mother’s pregnancy		
Birth and neo-natal period		
Breastfeeding		
Weaning, food access and dietary history		
Development		
Previous presentations, hospital admissions and medication use		
Dental hygiene and access to dental services		
Educational progress		
Family relationships, social circumstances, 
caring arrangements		
CURRENT ISSUES	CURRENT RISK FACTORS	

ALLERGIES/DRUG INTOLERANCE
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	
CURRENT MEDICATIONS (including prescription and over the counter and supplied by doctor without prescription)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	
RELEVENT FAMILY MEDICAL HISTORY 
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	

IMMUNISATION STATUS (referring to current age/sex schedule)	
TYPE	DATE	TYPE	DATE	

				

NEONATAL HEARING SCREENING (any ISSUES identified)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	
PARENTAL/OTHER CONCERNS ABOUT VISION ((eg. lazy eye, squint, infection, injury, family history of eyesight problems)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

PHYSICAL ACTIVITY	

IDENTIFIED ISSUES	
ACTION	

		

NUTRITION	

IDENTIFIED ISSUES	
ACTION	

		

ALCOHOL, TOBACCO AND OTHER SUBSTANCE USE	

IDENTIFIED ISSUES	
ACTION	

		

MOOD (depression and self harm risk)	

IDENTIFIED ISSUES	
ACTION	

		

SEXUAL AND REPRODUCTIVE HEALTH 	

IDENTIFIED ISSUES	
ACTION	

		

OTHER MEDICAL HISTORY AS INDICATED FOR PATIENT

Living conditions and exposure to environmental factors, including tobacco smoke	

IDENTIFIED ISSUES	
ACTION	

		

Other history considered necessary by doctor or collector (including stressful life events) 	

IDENTIFIED ISSUES	
ACTION	

		

MEDICAL EXAMINATION 

HEIGHT AND WEIGHT (plot and Interpret growth curve/calculate BMI) 	

IDENTIFIED ISSUES	
ACTION	

		

NEWBORN BABY CHECK – if not previously completed        (including red reflex check)	

IDENTIFIED ISSUES	
ACTION	

		

TEETH AND GUMS     normal          abnormal 

		

IDENTIFIED ISSUES	
ACTION	

		

EAR AND HEARING:  otoscopy      	

IDENTIFIED ISSUES	
ACTION	

		

VISION        (check eyesight – may include (but not limited to) visual inspection and using eye chart if appropriate)	

IDENTIFIED ISSUES	
ACTION	

		

OTHER MEDICAL EXAMINATION – AS INDICATED FOR PATIENT

 

TRACHOMA      (examine all children in remote communities and where indicated for others) 	

IDENTIFIED ISSUES	
ACTION	

		

SKIN (where indicated) 	

IDENTIFIED ISSUES	
ACTION	

		

RESPIRATORY EXAMINATION (if indicated)	

IDENTIFIED ISSUES	
ACTION	

		

CARDIAC AUSCULTATION (if indicated) – congenital heart disease/rheumatic heart disease	

IDENTIFIED ISSUES	
ACTION	

		

ASSESSMENT OF PARENT-CHILD INTERACTION (if indicated) 	

IDENTIFIED ISSUES	
ACTION	

		

DEVELOPMENTAL ASSESSMENT (age appropriate milestone) where appropriate 	

IDENTIFIED ISSUES	
ACTION	

		

Other examinations considered necessary by gp	

EXAMINATION
	
IDENTIFIED PROBLEMS	
ACTION	

			

iNVESTIGATIONS AS REQUIRED	
INVESTIGATION 		TESTS DONE 	TESTS ORDERED 	ARRANGEMENTS(eg referral details)

Haemoglobin testing				Date __/__/____			

Audiometry						Date __/__/____

Optometry					          Date __/__/____
	
Other………………………………………………………………………………………………………………………...
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

	

ASSESSMENT OF PATIENT 	
EXISTING HEALTH ISSUES	IDENTIFIED RISK FACTORS	

		

INTERVENTION ACTION 
HEALTH ADVICE PROVIDED TO PATIENT OR PARENT/CARER
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	
OTHER ACTION 
(including referrals, liaison with school or family focussed and preventative health interventions)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	

For information on this MBS item and its Explanatory Notes,
Visit the Department of Health website at www.health.gov.au/mbsonline