COMPREHENSIVE MEDICAL ASSESSMENT ITEM 712
Date completed: «datel»
Resident
Full name
Address
Date of Birth
Phone
Fax
«patientfullname»
«address1»
«address2»
«address3»
«medicarenoandsubnumerate»
«dvano»
«hccpensno»
Medicare
DVA
Pension
«dob»
«phoneh»
«phonef»
Medicare Exp
DVA Exp
Pension Exp
«medicareexp»
«dvaexp»
«hccpensexp»
Doctor / Referring GP
Doctor
Practice
Address
«docname»
«sitename»
«siteaddr1» «siteaddr2»
«siteaddr3»
Phone
Fax
«sitephone»
«sitefax»
Email
«docemail»
Phone
«selphone»
Fax
«selfax»
Email
«selemail»
Reviewing Pharmacist
Pharmacist
Address
«selname»
«selcompanyname»
«seladdr1» «seladdr2»
«seladdr3» «seladdr4»
RACF
RACF
details
Resident consent
«address1»
«address2»
«address3»
Consent given by
«nextofkin»
RACF
Phone:
«phoneh»
Next of kin Phone:
«nextofkinphone»
RACF Fax:
«phonef»
Date consent
given
«datel»
Advance care directive
Care
directive:
Power of
Attorney:
Details:
Relevant clinical information
«printclinicalhistory»
-1-
Medical
Cardiovascular
Respiratory
Examination
BP:
Pulse:
Other:
Chest
Gastro-Intestinal
Abdomen:
Identified Issues
Weight:
Height:
BMI:
Oral Health:
Nutrition:
CNS/Musculoskeletal
Hearing
Vision
Skin
Feet
Other
(if relevant)
Psychological and
behavioural
Cognition
(see Minimental
examination attached)
Pain
Sleep
 Normal
 Impaired
Wears Aids
 Normal
 Impaired
Aided: R
L
Unaided :
Ulcers
Yes
No
R
L
Other:
Pulses
sensation
eg. breasts, PR, vaginal
examination
Normal
Problems
Normal
Impaired
MMSE
/30
Acute
Yes
Chronic
Yes
Adequate
Inadequate
Pap Smear History: «lastpapdate»
No
No
Continence
Urinary Incontinence:
Yes
No
Faecal Incontinence:
Yes
No
Physical function
Urinalysis – if indicated
Protein:
Blood:
Glucose:
Mobility
independent
aid
assistance
not mobile
-2-
Recent Falls
Yes
No
ADLs
Assistance required
Smoking status
N/A N/A
Alcohol status
Nil N/A
SUMMARY
PROBLEMS IDENTIFIED
This patient needs:
GP Signature
GP Name:
ACTION REQUIRED
Care Plan contribution
Case Conference
Family Meeting
RMMR
Date
«datel»
«docname»
«docprov»
-3-