Nurse-Vorlage
Health Assessment 75+ years
Eine professionelle Nurse-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a comprehensive health assessment for your elderly patients? This 'Health Assessment 75+' template is perfect for nurses and other healthcare professionals. It helps streamline the process of gathering essential information about a patient's health, lifestyle, and needs. This template, when used with Heidi, ensures all key areas are covered, from family history and social habits to immunisations and ADLs. Easily generate detailed and accurate notes, saving you time and improving patient care. This template is ideal for creating thorough and efficient medical documentation, helping you to provide the best possible care for your patients.
Vorlagenvorschau
Advanced Care Directive:
2020. Reviewed with patient. No changes required.
Family History:
Mother is still living. Father passed away at age 82 due to a heart attack.
Social History:
Patient lives alone. She has two children and four grandchildren. She has a cat.
Home Living/Services:
Patient receives a home care package, level 3, provided by Aged Care Services. She receives assistance with cleaning and lawn mowing, once per week.
Recreation Activities:
Patient enjoys walking and knitting.
Alcohol and Tobacco Use:
Patient consumes approximately 5 standard drinks per week. Smoked 20 cigarettes per day from 1960 to 2000.
Immunisations:
Last COVID-19 vaccine dose received in March 2024. 2025 influenza vaccine recommended. Shingrix x2 received in 2023. Prevenar13 received in 2022. Whooping cough vaccine recommended every 10 years.
Medications:
Medications are up to date. No recent changes to medications. Takes a daily multivitamin.
Allergies:
No known allergies.
Mobility:
Patient’s mobility is good and she uses a walking stick. Balance is good. No falls in the past 12 months. Does not use a medical/falls alert buzzer.
Diet:
Patient eats 3 serves of fruit and 2 serves of vegetables per day. Eats takeaway or fast food once per month and dines out once per month. Drinks 8 glasses of water per day and 2 cups of tea per day. Breakfast is cereal with milk and fruit. Morning tea is a piece of fruit. Lunch is a sandwich. Dinner is chicken and vegetables.
Exercise:
Patient walks for 30 minutes, 3 times per week. Recommended at least 30 minutes of physical activity most days of the week.
Sleep:
Patient’s sleep is good. Sleeps for an average of 8 hours per night. Feels well rested most mornings. Does not nap during the day.
Bladder and Bowels:
No bladder or bowel problems. Patient is regular and continent.
Hearing:
Patient’s hearing is good. Does not use hearing aids. Last hearing check occurred in 2023.
Vision:
Patient wears glasses for reading. Optometrist is Dr. Smith, next review due in December 2024. Does not see an ophthalmologist.
Teeth:
Patient has natural teeth.
Activities of Daily Living (ADLs):
Patient is independent in all ADLs.
Driving:
Patient has an unrestricted driver’s license.
Skin Check:
Last skin check was in 2023, next due in 2025.
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