<<Miscellaneous:Practice Letterhead>>

ADULT HEALTH CHECK
<<Miscellaneous:Date>>

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

Doctor
<<Doctor:Name>> , <<Doctor:Qualifications>>

Patient Consent?	Yes ( ),	<<Miscellaneous:Date>>

Previous Health Check?	No ( )	Yes ( ), date                                 

HISTORY

Past Medical History
<<Clinical Details:History List>>

Current Medical Problems

•	

Risk Factors
Smoking - <<Clinical Details:Smoking>>
Alcohol - <<Clinical Details:Alcohol>>

Family History
<<Clinical Details:Family History>>

Social History
<<Clinical Details:Social History>>
Is patient carer?	Yes ( )	No ( )
Is patient in care?	Yes ( )	No ( )

Pap Smears/Sexual Health
<<Clinical Details:Pap Smears>>

Medication
<<Clinical Details:Medication List>>
Immunisation
<<Clinical Details:Immunisation List>>

Hearing loss
Yes ( )	No ( )

Mood 

Examination

BP:					HR:						Rythm:
Height:				Weight:

Oral examination:

Visual Acuity:

Otoscopy:

Hearing tests if required:

Proteinuria?	Yes ( )		No ( )

Investigations

Ordered:

Interventions

Risk Factors:
1.	

Interventions required:

Strategy for good health

•	Moderate to vigorous exercise 30 minutes per day.
•	Maintain a healthy diet - low in fat and sugar, high in fruits and vegetables 
•	Maintain healthy weight
•	Regular check ups

Reminder for next Adult Health Check?  yes ( ) , no ( ).