Health Assessment 75+ years

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.