Intellectual disability health assessment

Clinician Specialty: General Practitioner **Health Assessment for a Person with Intellectual Disability** "Patient consents to participating in health assessment - verbal consent" Patient: Sarah Jenkins DOB: 15/05/1990 Carer present: yes Date: 1 November 2024 GP: Dr. Eleanor Vance **1. Time-Tiered Item Selection (Medicare)** "701/703/705/707" "Claimable once every 12 months per eligible patient." **2. Checklist (Consult Prompts)** **A. History & Function** Physical, psychological, and social function reviewed: Patient presents with mild intellectual disability. Physical function stable, participates in light recreational activities. Psychological function stable with occasional anxiety related to changes in routine. Social function adequate with family and support worker. ADL supports adequate: yes, uses support worker for complex tasks like financial management and medical appointment scheduling. Mental health / comorbidities: * Mild Anxiety Disorder * Hypothyroidism (controlled with medication) Seizure history: No history of epilepsy. **B. Examination & Screening** Dental: normal, regular dental check-ups. Hearing (audiometry <5y?): yes Vision (eye check <5y?): yes Height / Weight / BMI: Height: 160 cm, Weight: 70 kg, BMI: 27.3 (overweight) Nutrition: concern, patient tends to prefer processed foods, working on healthier choices with support worker. Bowel/bladder: normal Dysphagia / GERD (esp CP): no Abuse concerns considered: yes, discussed with patient and carer, no concerns identified. **C. Medications** Prescribed meds reviewed: yes Non-prescription meds reviewed: yes Side effects / interactions discussed: Discussed potential side effects of levothyroxine, patient reports no issues. No significant interactions identified with current medications. Carer education provided: yes Medication review needed: no Medication list: * Levothyroxine 75mcg daily * Sertraline 50mg daily **D. Preventive Health** Immunisations: up to date Exercise: inadequate, patient struggles with motivation for regular exercise. Screening as per general population: Breast exam / Mammogram: yes Cervical screening: yes Testicular exam: NA Lipids: yes Osteoporosis risk assessed: yes Thyroid function: 1 November 2024 / next due 1 November 2025 **3. Management Plan** Key issues identified: * Management of overweight status and nutrition. * Encouraging regular exercise. * Ongoing monitoring of anxiety. Preventive care initiated: Referral to dietician for nutritional guidance. Discussed strategies to incorporate more physical activity into daily routine. Referrals: * Dietician * Local walking group Lifestyle advice: Encouraged daily walks and mindful eating. Suggested joining a local social group to increase physical activity and social interaction. **4. Reporting & Documentation** Written summary offered to patient: yes Copy to carer (with consent): yes "Report saved in notes"