Health assessment for patient with a disability
Date: 

Patient details	
Name: 	 	
DOB: 	 	
Sex: 	 	
Support person:	 	Relationship (e.g. parent/carer):	 	
Aboriginal and/or Torres Strait Islander status:	 	
Patient consents to health assessment: 	 	
Medical alerts: 	 	

Allergies and drug intolerances (list these)	

Medication review	
Current medications? (insert medication list):	

Assess medications: 	 	
Home medication review required? 	 	
Education required? 	 	

Observations	
Height: 	 	
Weight: 	 	
Blood Pressure: 	 	
Pulse Rate:	 	
Waist circumference (optional):	 	

If the person has a weight / blood pressure concern, please specify action taken:	
Weight control: 	 	
Hypertension: 	 	

Systems Check
Please perform a complete comprehensive physical examination:	
Cardiovascular: 	 	
Respiratory: 	 	
Musculoskeletal: 	 	
Renal/Urogenital: 	 	
Endocrine: 	 	
Gastrointestinal: 	 	
Nervous: 	 	
Skin: 	 	
Psychiatric/behavioural: 	 	
Cognition: 	 	
Mood: 	 	
Self harm risk: 	 	
Mental health: 	 	

Nutritional status / growth and development review	
Activity and Lifestyle:	 	
Exercise?	 	
Diet?	 	
Eating behaviours?	 	
Referral required?	 	

Alcohol, how many standards drinks per day/week?	 	
Smoking (include cigarettes, tobacco, vapes, e-cigarettes and other substances), how many a day/week?	 	
If ex-smoker, when was smoking ceased?	 	
Is substance abuse suspected?	 	

Epilepsy (if present)	
Has the person’s seizure control been reviewed?	 	
Has a referral been considered? 	 	
Is an epilepsy management plan completed, if so, is it current? 	 	
Has the risk of Sudden Unexpected Death in Epilepsy (SUDEP) been minimised? 	 	
 
Vision
(If abnormal, unable to test or uncertain, consider referral)	
Recent review and testing?	 	
If so, when was it completed?	 	
Test result:	 	
Both eyes:	 	
Right:	 	
Left:	 	
Concerns with testing?	 	
Any visual concerns noted?	 	

Hearing 
(If hearing test or otoscopy abnormal, unable to test or uncertain, consider referral)	
Recent review and testing?	 	
If so, when was it completed?	 	
Test result:	 	
Both ears:	 	
Right:	 	
Left:	 	
Concerns with testing?	 	
Has an otoscopy been performed?	 	
Appearance:	 	
Any hearing concerns noted?	 	

Aetiology
(If no results, consider referring to a genetics clinic)	
Recommend a CGH Microarray?	 	
Recommend testing for Fragile X?	 	

Sleep 	
Sleep apnoea?	 	
Sleep problems? 	 	
Comments:	 	

Women's Health	
Breast examination? 	 	
Is a mammogram required?	 	
If so, referral completed?	 	
Cervical screening undertaken? 	 	
Reminder set (if required)?	 	
Pain or concerns present?	 	

Men's Health	
Undescended testicles?	 	
Prostate screening?	 	
Pain or concerns present?	 	

GIT and Bladder Function	
Chronic constipation?	 	
Dysphagia?	 	
Gastro-oesophageal disease?	 	
Urinary incontinence?	 	
Bowel incontinence?	 	

Sexual and reproductive health	
Sexually active?	 	
Contraception?	 	
STI screening?	 	
Education required?	 	
Pain or concerns present?	 	

Abuse	
Signs of physical, psychological, or sexual abuse?	 	
Any concerns noted?	 	

Dental Health	
Last dental review?	 	
Any concern noted? 	 	

Health Promotion and Screening	
Recent blood test?
(insert results)	 	
Colorectal cancer assessment?	 	
Osteoporosis risk assessed?	 	
Immunisations up to date?	 	
If not, what is due?	 	
Scripts given?	 	

Future Planning	
Mobility changes?		
Functional decline over time? 		
Recent fall/s?		
Activities of daily living (ADLs) concerns?		
Are the following present in the home:	
- hand rails?		
- rugs on floors?		
- tripping hazards?		
- space to manoeuvre?		
- pets?		
- steps?		
- uneven surfaces?		
- adequate lighting?		
- accessibility concerns?		
Would you be surprised if the person were to die in the next 12 months?		
Have you considered advanced care planning and palliative care, and discussed with the
person, their family or carers?		

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