Preventive health assessment 45-49 years

PREVENTIVE HEALTH ASSESSMENT 45-49 YEARS

CONSENT 
Health Assessment explanation given: Yes
Consent for health Assessment obtained from patient: Yes

CURRENT PATIENT CONCERNS

GENERAL HEALTH RISK ASSESSMENT [+] risk identified, [-] no risk identified
[-] smoking/vaping history. 
[-] alcohol use. 
[-] physical activity [-] exercise at least 30 minutes walking or equivalent 5 or more days per week.
[-] sleep. 
[-] dental health. 
[-] significant active medical condition/s. 
[-] regular medications. 
Comments: 
-

Medical support:
[-] Seen by any other doctor/specialist in the last six months?
[-] Regular health care from any other source (Allied/Pharmacist/Alternative/Other)?
Comments:  
-

Nutrition assessment (daily intake):
[+] 4-7 serves vegetables/legumes
[+] 4-6 serves bread/cereals/rice/pasta
[+] 2-3 serves fruit
[+] 2-3 serves milk/yogurt/cheese
[+] 1-2 serves lean meat/fish/poultry/eggs/nuts
[+] Consume six or more cups of fluid most days
[+] Swallowing and eating without difficulty
[+] No loss or gain in weight > 5 kg in last 6 months
Comments: 
-

CANCER RISK ASSESSMENT (risks identified [-] screening arranged)
[-] FOB Every 2Y from 50-74Y (from 25Y if high risk). 
[-] Skin cancer

Women:
[-] Breast cancer [-] mammography. Every 2Y from 50-74Y (from 40Y if elevated risk).
[-] Cervical cancer screening. Every 5Y from 25-74.

Men:
[-] Prostate cancer screening (PSA).
Offer two-yearly testing to all men aged 50-69. If total PSA is 3.0 µg/L or greater, repeat the test within 1-3 months, and, if confirmed, offer a referral for further investigation. 
Recommended for men starting at age 40 at higher risk of prostate cancer:
  [-] FHx prostate cancer, especially first-degree relative diagnosed <65 years of age.
  [-] Ancestry: sub-Saharan, Aboriginal and Torres Strait Islander men.
  [-] BRCA carrier.

Comments: 
-

CARDIOVASCULAR RISK ASSESSMENT
[-] BP: 
[-] Blood lipids. Every 5Y from 45Y; every 12M from 35Y if elevated risk. 
Comments: 
-

INFECTIOUS DISEASES RISK ASSESSMENT
[-] STI screen. Opportunistically sexually active people to 29Y or if risks identified.
Comments: 
-

IMMUNISATIONS (recommended)
[-] Influenza: Every year.
[-] Covid-19. 
[-] Pneumococcal: ATSI @ 50Y[+] (13vPCV then 23vPPV 2–12 months later, then 23vPPV at least 5Y later).
[-] DTPa (Pertussis): Every 10Y.
[-] DTPa (Pertussis): Pregnant women [-] each pregnancy @ 20-32/40.
[-] HPV: Single dose, if missed @ 12-13Y, up to 25Y (3 doses if >25Y).
[-] Other immunisations may be required for some medical conditions.
Comments: 
-

MENTAL HEALTH RISK ASSESSMENT
[-] anxiety
[-] bullying
[-] child abuse history
[-] cognitive decline
[-] depression
[-] gambling
[-] intimate partner violence
[-] loneliness
[-] secure accommodation
[-] personal safety
[-] responsible for caring for someone else
Comments: 
-

METABOLIC HEALTH RISK ASSESSMENT
[-] Renal function (creatinine). Every 1-2Y if elevated risk from 30Y.

Height (cm): 
Weight (kg): 
BMI [20-25]: 
Waist measurement (cm): 
  (Asian or ATSI descent - women < 80 cm, men: less < 90 cm)
  (All others - women < 88 cm, men < than 102 cm)

Comments: 
-

MISCELLANEOUS RISK ASSESSMENT (if indicated)
[-] Vision. 
[-] Hearing. 
[-] Pre-conception care [-] opportunistically, child-bearing age

[-] Family History Screening Questionnaire (FHSQ) [-] every 3Y
[-] Activity status questionnaire [-] if concerns about function
[-] Cardiovascular risk assessment [-] every 5Y from 45-79Y
[-] Diabetes mellitus risk assessment [-] every 5Y from 40-79Y

[-] Fracture/osteoporosis risk assessment - all 50Y+, and post-menopausal women

Comments: 
-

RISK SUMMARY
[+] 
[-]

PLAN INCLUDING REFERRALS (investigations requested)
[-] ECG: 
[-] Spirometry:

[-] FBE: 
[-] EUC / LFT: 
[-] Lipid Profile: 
[-] TFT: 
[-] B12 & Folate: 
[-] Iron Studies:

[-] PSA:

[-] Cervical screening test (perform every 5 years from 25-74 years):

[-] Breast screen (perform every 2 years from 50-74 years):

[-] Bowel cancer screening (free test every 2 years from 50 years):

RESOURCE RECOMMENDATIONS
[-] Smoking: Quitline 137 848, [www.quit.org.au]
[-] Nutrition: The Australian Guide to Healthy Eating 1800 020 103, [www.healthyactive.gov.au] 
[-] Alcohol: National Alcohol and Other Drug Hotline 1800 250 015, [https://campaigns.health.gov.au/drughelp] 
[-] Physical activity: An active Way for Better Health, 1800 020 103, [www.healthyactive.gov.au] 
[-] Blood pressure: HeartLine 1300 362 787, [www.heartfoundation.org.au] 
[-] Osteoporosis: Osteoporosis Australia 8379 5711, [www.osteoporosis.org.au] 
[-] Cancer screening: [https://www.health.gov.au/health-topics/cancer/cancer-screening]

REFERRALS

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

Notes

Medicare Australia Item Numbers:

701: <30 minutes
703: 30-44 minutes
705: 45-59 minutes
707: >60 minutes

Preventive health assessment 45-49 years

Notes

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