Comprehensive Health Assessment Screening Form
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Date of Assessment
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Person Performing Assessment
First Name
Last Name
GENERAL HEALTH STATUS
Current Health Conditions
Medications
Rows
Medication
Dose
Frequency
Service Quality
Cleanliness
Responsiveness
Friendliness
Allergies
Any known drug or environmental allergies
PHYSICAL HEALTH REVIEW
Weight (kgs)
Height (cm)
Vision and Hearing
Date of last check-up and results, if available
Oral Health
Last dental visit and findings
Mobility
Independent
Requires Assistance
Dependent
Mobility Aid
Skin Health
Check for pressure ulcers, rashes or other skin issues
MENTAL HEALTH & BEHAVIOURAL OVERVIEW
Psychiatric History
Any recent diagnosis or behavioural changes
Mood & Behaviour
Notable changes or concerns such as aggression, anxiety, withdrawal
Cognitive Function
Overview of cognitive status or any recent evaluations
Medical Screening
Have you had any cancer screenings recently (e.g. Mammogram, colonoscopy, pap smear, prostate exam)? If so, when was the last one, and what were the results?
Cholesterol Screening
When was the most recent cholesterol screening? Did you receive any results for your cholesterol levels (LDL, HDL, triglycerides)?
Diabetes Screening
Have you been tested for diabetes recently? If so, what were the results of your last blood glucose or HbA1c test?
Health Concerns Raised
Are you currently seeing any specialists for your health conditions?
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