Heart Health Assessment (MBS items 699 & 177)

<<Miscellaneous:Date (short)>>

Patient details:
Name: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
Gender: <<Patient Demographics:Gender>>

Patient history:
<<Clinical Details:History List>>

Smoking: <<Clinical Details:Smoking>>
Alcohol: <<Clinical Details:Alcohol>>

Family history: 
<<Clinical Details:Family History>>

Physical examination including blood pressure performed? <<Physical examination performed (including B.P.)?>>

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

Interventions or referrals required to address risk factors? <<Interventions or referrals required to address risk?>>
Details:
<<Details of interventions or referrals required>>

Lifestyle modification program/s recommended? <<Lifestyle modification program/s recommended?>>
My Health for Life <<My Health for Life>>
10,000 Steps Program <<10,000 Steps Program>>
Rural and Allied Community Health Services - North Burnett <<Rural and Allied Community Health - North Burnett>>
Get Healthy <<Get Healthy>>
The COACH Program <<The COACH Program>>
Quitline <<Quitline>>
Heart Foundation Walking Groups <<Heart Foundation Walking Groups>>
BUPA Health Management <<BUPA Health Management>>
Medibank <<Medibank >>
Move4Medicine <<Move4Medicine>>

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

Preventative healthcare advice and information provided? <<Preventative healthcare advice and info provided?>>
Comments:
<<Comments on information and advice provided>>

Medications (selected):
<<Clinical Details:Medication List>>

Measurements: 
<<Clinical Details:Measurements>>

Investigation results (selected):
<<Summary:Investigation Results (Selected)>>

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 v0419MD created by CQ,WB,SC PHN 12.04.19