Health Assessment 75+

Advanced Care Directive

• The patient's Advanced Care Directive was completed in 2021. Reviewed with patient. No changes required.

Family History

• Both the patient's mother and father are deceased.
• The patient's father passed away at age 79 due to an acute myocardial infarction.
• The patient's mother passed away at age 86 due to complications from cerebrovascular disease.
• The patient has one living sister who has a history of hypertension and osteoarthritis.

Social History

• The patient lives alone in a single-storey brick home.
• The patient has two children and four grandchildren.
• The patient has one cat and two great-grandchildren.

Home Living/Services

• The patient does not currently have a Home Care Package.
• The patient receives services through the Commonwealth Home Support Program (CHSP).
• The patient receives assistance with domestic cleaning once a fortnight and lawn mowing once a month.
• The patient is managing well at home with current supports.
• Home adaptations include grab rails installed in the shower and toilet, and a small ramp at the back door.

Recreation Activities

• The patient enjoys daily crosswords, reading novels, and attending the local bowls club once a week for social bingo.

Alcohol and Tobacco Use

• The patient consumes 3 standard drinks per week, typically a small glass of red wine with dinner on weekends.
• The patient is an ex-smoker who commenced smoking in 1968 and ceased in 1995, having smoked an average of 15 cigarettes per day.

Immunisations

• The patient received a COVID-19 booster dose in November 2024.
• The patient received the 2025 influenza vaccine in April 2025.
• The patient received two doses of Shingrix in 2024.
• The patient received Prevenar 13 in 2021.
• The patient has not received a recent pertussis vaccine; a booster is recommended every 10 years.

Medications

• Up to date
• Perindopril was reduced from 8 mg to 4 mg PO daily last month due to mild postural dizziness.
• The patient takes colecalciferol (vitamin D3, Ostelin®) 1,000 IU PO daily and paracetamol (Panadol Osteo®) 1,330 mg PO TDS PRN for knee pain.

Allergies

• The patient has a documented allergy to amoxicillin, which causes a generalised maculopapular rash.

Mobility

• The patient mobilises independently indoors and uses a single-point walking stick when walking outdoors in the community.
• The patient's balance is fair.
• The patient has not had any falls during the past 12 months.
• The patient wears a personal medical alert pendant at all times.

Diet

• The patient consumes 2 servings of fruit and 3 servings of vegetables daily.
• The patient rarely eats takeaway or fast food and dines out at the local club once a fortnight.
• The patient drinks 5 glasses of water each day.
• The patient drinks 2 cups of black tea and 1 cup of instant coffee each day.
• Breakfast: Rolled oats with low-fat milk and a banana.
• Morning tea: One plain sweet biscuit with a cup of tea.
• Lunch: Wholemeal sandwich with tinned tuna, lettuce, and tomato.
• Dinner: Grilled chicken or fish with steamed seasonal vegetables, or a homemade beef casserole.

Exercise

• The patient performs gentle stretching exercises at home daily and walks around the neighbourhood block for 20 minutes three times a week.

Sleep

• The patient's sleep is generally good.
• The patient retires at 22:00 and wakes at 06:00, achieving an average of 7 hours of sleep per night after accounting for one brief nocturnal awakening.
• The patient feels well rested on most mornings.
• The patient occasionally naps for 20 minutes in the armchair after lunch.

Bladder and Bowels

• The patient reports nocturia once per night, which is stable and not bothersome.
• The patient is a male and reports a slightly slowed urinary stream without hesitancy, dysuria, or incomplete emptying.
• The patient is regular and fully continent of both urine and faeces.

Hearing

• The patient has mild bilateral sensorineural hearing impairment, particularly noticeable in noisy environments.
• The patient uses bilateral behind-the-ear hearing aids.
• The patient's hearing was last assessed at Hearing Australia in August 2024.

Vision

• The patient wears multifocal glasses for both reading and distance vision.
• The patient sees optometrist Sarah Jenkins at OPSM, with the next review due in October 2025.
• The patient sees ophthalmologist Dr David Vance for monitoring of early cataracts, with the next review due in February 2026.

Teeth

• The patient has a combination of natural lower teeth and a partial upper denture.
• The patient wears a partial upper denture which fits comfortably without ulceration.

Activities of Daily Living (ADLs)

• The patient is independent in all personal ADLs, including showering, dressing, toileting, and feeding.
• The patient requires assistance only with heavy domestic chores and garden maintenance.

Driving

• The patient holds a conditional driver's licence requiring corrective lenses.
• The patient limits driving to daylight hours within a 15 km radius of home.

Skin Check

• The patient's last skin check was completed on 14/05/2024, and the next annual skin check is due in May 2025.