Heart Health Assessment (MBS items 699 & 177)

<TodaysDate>

Patient details:
<PtDetails>
DOB: <PtDoB>
Sex: <PtSex>

Patient history (selected):
<SelectedPMH>

Smoking status: <SmkStatus>
Smoking history: <SmkHx>
Alcohol history: <AlcHx>

Family history: 
<FamilyHx>

Physical examination including blood pressure performed? <Physical examination including blood pressure performed?>

Cholesterol checked in last 12 months? <Cholesterol checked in last 12 months?>

Interventions or referrals required to address identified risk factors? <Are any interventions or referrals required to address identified risk factors?>
Details: 
<Details>

Lifestyle modification program/s recommended? <Are any lifestyle modification program/s recommended?>
Program/s recommended: <Program/s recommended>

Management plan needed to treat risk? <Is a management plan needed to treat identified risk/s?>
Comments: 
<Comments>

Preventative health care advice and information required? <Preventative health care advice and information provided?>
Comments: 
<Comments on information and advice provided>

Medications (selected): 
<SelectedRx>

Observations (selected):
<Observations>

Investigation reports: 
<Ix>

Absolute cardiovascular risk score: <Absolute cardiovascular risk score>
ECG performed: <ECG performed?> ECG result: <ECG result>
Comments: 
<Comments on ECG>

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Heart Health Assessment template v0419BP created by CQ,WB,SC PHN 12.04.19