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

Older Person (55+) Health Assessment

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 for the health assessment found at www.health.gov.au/mbsonline.

Patient’s Name ………………………………………….. Aboriginal	Torres Strait Islander
Works status ……………………………………………..

Male	Female	DOB:   /   /	or Age: 	 
Aboriginal and Torres Strait Islander

Current contact details
Address    …………………………………………………. Phone ……………………………………………………

Alternative contact details …………………………….. Address …………………………………………………. Phone ……………………………………………………

Patient Consent
Explanation of health check given	Yes Patient consent for health check given Yes

Consent given for information to be collected by:
Aboriginal and Torres Strait Islander health practitioner

Date consent was given:

    /    /_ 	

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
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

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 PATIENT
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………	
Next appointment with doctor:
Next Health Assessment:	Date:     /   / 	
Date:     /   / 			
GP: Dr. ……………………………………….	GP’s signature ……………….…………….	Date:     /   / 		

CURRENT ISSUES	
CURRENT RISK FACTORS	

		

MEDICAL HISTORY		
FAMILY RELATIONSHIP

Does the patient care for someone else?	

No	

Yes	

Is the patient cared for by someone else?	
No	
Yes	

ALLERGIES/DRUG INTOLERANCE
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………… CURRENT MEDICATIONS
(including prescription and over the counter and supplied by a doctor without prescription)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

RELEVENT FAMILY MEDICAL HISTORY
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

IDENTIFIED ISSUES	
ACTION	

		

……………………………………………………………………………………………………………………………… CONTINENCE

IMMUNISATION STATUS – INFLUENZA, TETANUS AND PNEUMOCOCCUS
(referring to current age/sex schedule)
TYPE	DATE	TYPE	DATE	

				

ACTIVITIES OF DAILY LIFE

IDENTIFIED ISSUES	
ACTION	

		

FALLS IN THE LAST 3 MONTHS

IDENTIFIED ISSUES	
ACTION	

		

NUTRITION

IDENTIFIED ISSUES	
ACTION	

		

ALCOHOL, TOBACCO AND OTHER SUBSTANCE USE

IDENTIFIED ISSUES	
ACTION	

		

HEARING LOSS

IDENTIFIED ISSUES	
ACTION	

		

VISUAL ACUITY (ask about clarity and comfort of vision at distance and near)

IDENTIFIED ISSUES	
ACTION	

		

COGNITION

IDENTIFIED ISSUES	
ACTION	

		

MOOD

IDENTIFIED ISSUES	
ACTION	

		

AVAILABILITY OF HELP

IDENTIFIED ISSUES	
ACTION	

		

CARING FOR ANOTHER PERSON

IDENTIFIED ISSUES	
ACTION	

		

MEDICAL EXAMINATION

BLOOD PRESSURE: …………………	PULSE RATE AND RHYTHM:  Normal	Abnormal

IDENTIFIED ISSUES	
ACTION	

		

WEIGHT: ……...	HEIGHT: ……...	BMI: ……...	Weight circumference (if indicated): ……...

IDENTIFIED ISSUES	
ACTION	

		

GUMS AND DENTITION:	Normal	Abnormal

ACTION	

		

EAR AND HEARING:  Otoscopy	Whisper test (if indicated)

IDENTIFIED ISSUES	
ACTION	

		

URINALYSIS

IDENTIFIED ISSUES	
ACTION	

		

TRICHIASIS	(Note: Examine those people who have grown up in remote communities or have a history of ‘sore or watery eye’)

IDENTIFIED ISSUES	
ACTION	

		

SKIN

IDENTIFIED ISSUES	
ACTION	

ENVIRONMENTAL AND LIVING CONDITIONS

IDENTIFIED ISSUES	
ACTION	

		

VISUAL ACUITY	Normal	Abnormal	(Test near and distance visual acuity)

IDENTIFIED ISSUES	
ACTION	

		

OTHER EXAMINATIONS CONSIDERED NECESSARY BY GP

EXAMINATION	
IDENTIFIED PROBLEMS	
ACTION	

			

INVESTIGATIONS AS REQUIRED
INVESTIGATION
Fasting blood sugar	TESTS DONE	TESTS ORDERED
Date    /__/_ 		ARRANGEMENTS(eg referral details)	
Lipids

Pap Smear		Date    /__/_ 	

Date    /__/_ 			
STI		Date    /__/_ 			
Mammography		Date    /__/_ 			
Optometry		Date    /__/_ 			
Other:………………………………………………………………………………………………………………………...
……………………………………………………………………………………………………………………………….

ASSESSMENT OF PATIENT
(based on consideration of evidence from patient history, examination and results of any investigation)

EXISTING HEALTH ISSUES	
IDENTIFIED RISK FACTORS	

		

INTERVENTION ACTION

HEALTH ADVICE PROVIDED TO PATIENT
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

OTHER ACTION (if any)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

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