Aboriginal and Torres Strait Islander Health Check (birth - 5 years)
MBS items 715 VR/228 non-VR

About the health check 		
Eligible for health check (not claimed 715 or 228 in past nine months): 
	<<Eligible for health check (not claimed in last 9 mths)>>
 	
Consent	
Consent given by parent/primary carer after discussion of process and benefits of a health check: 	<<Consent given by parent/primary carer>>	
Parent/primary caregiver present for health check
Relationship to child:	<<Parent/primary caregiver present for health check>>
<<Relationship to child>>	
Date: <<Miscellaneous:Date (short)>>	Nurse/Aboriginal Health Worker: <<Miscellaneous:Current User>>	
Doctor:	<<Doctor:Name>>ProviderNo: <<Doctor:Provider Number>>	
Patient details	
Name: <<Patient Demographics:Full Name>>	Date of birth: <<Patient Demographics:DOB>>	Age: <<Patient Demographics:Age>>	Gender: <<Patient Demographics:Gender>>	
Aboriginal and/or Torres Strait Islander status: 	<<Patient Demographics:ATSI>>			
Parents/primary carer/s:	<<Parents / primary carers>>			
Social History: <<Clinical Details:Social History>>	
Address: <<Patient Demographics:Address>>	
Home phone: <<Patient Demographics:Phone (Home)>>	Mobile phone:<<Patient Demographics:Phone (Mobile)>>	
Emergency contact: <<Patient Demographics:Emergency Contact>>	Relationship to child:<<Patient Demographics:Emergency Contact Relationship>>	Emergency contact phone:<<Patient Demographics:Emergency Contact Phone>>	
Medicare number:<<Patient Demographics:Medicare Number>>	Expiry: <<Patient Demographics:Medicare Expiry Date>>		
Pension/Health Care Card number: <<Patient Demographics:Pension Number>>	
Registered for Closing the Gap 
PBS Co-payment Measure (CTG):	<<Registered for CTG:>>	
Registered for NDIS:	<<Registered for NDIS:>> No. <<If yes, NDIS No.>>	

Assessment	Health priorities, actions and follow-up	
Current health/patient priorities
What are the important things for you in this health check today? 
Is there anything that you are worried about with your child’s health or wellbeing?	
<<What are the important things in this health check:>>
<<Any worries about yr childs health/wellbeing?>>	
Medical history and current problems
Gestation at birth (weeks):
Recurrent cough or chest infections
 Recurrent ear infections/CSOM (glue ear/grommets)
 Growth or development problems
 Acute rheumatic fever/rheumatic heart disease 
(in high prevalence setting)
 Environmental exposure to tobacco smoke (eg at home, in car)
 Hospital admissions	Gestation at birth (weeks) : <<Gestation at birth (weeks) >>
Birth weight: <<Birth weight>>
<<Pregnancy complications>> Pregnancy complications:
<<Birth complications>> Birth complications
<<Problems after birth>> Problems after birth
<<Recurrent cough or chest infections>> Recurrent cough or chest infections
 <<Recurrent ear infections/CSOM>> Recurrent ear infections/CSOM (glue ear/grommets)
 <<Growth or development problems>> Growth or development problems
 <<Acute rheumatic fever/rheumatic heart disease>> Acute rheumatic fever/rheumatic heart disease 
(in high prevalence setting)
 <<Environmental exposure to tobacco smoke>> Environmental exposure to tobacco smoke (eg at home, in car)
 <<Hospital admissions>> Hospital admissions
	
Regular medications: check if still required, appropriate dose, understanding of medication and adherence
<<Clinical Details:Medication List>>	Does your child take any regular medications (prescribed, over-the-counter, traditional, complementary and alternative)?
<<Does your child take any regular medications?>> Understanding and adherence checked <<Meds - Understanding and adherence checked?>> 
Details: 	
Allergies/adverse reactions 	<<Clinical Details:Allergies/Adverse Reactions>>	
Relevant family history	<<Clinical Details:Family History>>	

Assessment	Health priorities, actions and 
follow-up	
Social history: Information about family and child’s 
living arrangements 
Who lives in your household?/Who does the child live with?
Have there been any stressful life events that would cause you or your child to be upset?	Details: 
<<Who does the child live with?>>
<<Any stressful life events that would cause upset?>>
Details:
	
Learning and development
Questions that support a conversation about learning and development:
•	Is there anything you are worried about with your childs development?
•	Is there anything that you are worried about with your child’s behaviour?
•	Is there anything that you are worried about with your child’s sleep?
•	Does your child go to childcare / early learning centre / kindergarten? How often?
•	How often does your child miss childcare/early learning centre/kindergarten?	Details: 
<<Any concerns re yr childs development?>>
	
Feeding and healthy eating
Is there anything that you are worried about with your child’s feeding / eating? 
Document conversation about age-appropriate healthy eating, which could include:
•	current diet 
•	transition to solids
•	recommendations about fruit and vegetable intake, water as the main drink, avoiding sugary drinks, avoiding highly processed foods (including supermarket-bought and take-away like KFC, Maccas)
Are there any issues about availability of food?	
<<Any worries with your childs feeding/eating?>>
Breastfeeding history:
Bottlefeeding history:
<<Are there any issues about availability of food?>>
If yes, provide details: <<If yes, provide details:>>	
Physical activity and screen time 
Is there anything that you are worried about with your child’s level of physical activity? 
Is there anything that you are worried about with your child’s level of screen time? 
Document conversation about age-appropriate recommendations re physical activity and screen time.	Physical Activity
<<Any worries about yr childs level of physical activity>>
<<Detail any concerns about level of phycisal activity>>

Screen Time
<<Any worries re your child’s amount of screen time?>>
<<Detail any concerns about amount of screen time>>	
Eye health
Is there anything that you are worried about with your child’s vision? 

	<<Any worries with your childs vision?>>
<<Detail any concerns about childs vision>>
Eye examination	
Red reflex (up to six months): 

R            L

Evidence of squint or other abnormality: 

R            L

Visual acuity (child aged three to five years): 

R            L	
Ear health and hearing
Document concerns with childs listening, language and noisy breathing/snoring while asleep.
Ear examination
Otoscopy (video otoscopy if possible, allows for parental education and for images to be saved for tracking over time)
Otoscopy findings (may be more than one of these):	

Left ear

Clear and intact

 Dull and intact

 Discharge

 Grommet in canal

 Grommet in eardrum

 Perforation

 Red/bulging

 Retracted

 Unable to view eardrum

 Wax

 Other:	
Right ear

Clear and intact

 Dull and intact

 Discharge

 Grommet in canal

 Grommet in eardrum

 Perforation

 Red/bulging

 Retracted

 Unable to view eardrum

 Wax

 Other:	

	Details:
Is there anything that you are worried about with your child’s listening?
<<Any worries about your child’s listening?>>
Is there anything you are worried about with your child’s language/talking?<<Any worries about your childs language/talking?>>
Do you notice snoring/noisy breathing at night/while your child is sleeping? <<Any snoring/noisy breathing at night/while sleeping>>
Last hearing test (audiology): <<Date of last hearing test / audiology>> 
	
Oral and dental health
Is there anything that you are worried about with your child’s teeth or mouth? 
Teeth and mouth check 
Document conversation about oral health and care of teeth
	Details:
<<Any worries about your childs teeth or mouth?>>
Date of last dental checkup:  <<Date of last dental checkup:>>
Examination findings: 
<<Teeth and mouth check examination findings>>	
Skin
Does your child have any skin problems? 
Document conversation about sun protection as appropriate (ie sunscreen, hats, shade)	Details: 
Does your child have any skin problems? <<Does your child have any skin problems?>>   
<<Details if skin problems:>>
General skin examination 
Examination findings: 
<<General skin examination findings:>>	
Immunisation: Check Child Health Record/Book and Australian Immunisation Register 
Immunisations up-to-date and recorded on Australian Immunisation Register (as per Australian immunisation handbook)? (PI 04)
https://immunisationcalculator.sahealth.sa.gov.au/ImmuCalculator.aspx 
	Details:
Immunisations up-to-date and recorded on AIR <<Immunisations up-to-date and recorded on AIR>>
Immunisations due: 
<<Immunisations due>>
Vaccines given today recorded on Australian Immunisation Register? 
<<Vaccines given today recorded on AIR>>	
Examination: growth measures recorded on Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) growth charts for centile and tracking overtime
	Growth measures
Length/Height: <<Clinical Details:Measurements (Selected)>>
Weight: <<Clinical Details:Measurements (Selected)>>
Head circumference: <<Head circumference>>
Heart rate and rhythm: <<Heart rate and rhythm>>
Cardiac auscultation: <<Cardiac auscultation>>
Abdominal examination: <<Abdominal examination>>
Gait examination (musculoskeletal structure, balance, coordination): <<Gait examination>>
Newborn examination (if indicated <= 6 weeks)
Haemoglobin (children at risk of iron deficiency anaemia):	

Finalising the health check	
Patient priorities and goals: What does the parent/carer and child say are the important things that have come out of this health check?<<Important outcomes of health check (parent/carer)>>	
Brief intervention: Advice and information provided during health check, for example:	

  Healthy eating, incl breastfeeding	

  Screen use	

  Sun protection	

  Environmental exposure to harmful elements (eg tobacco smoke)	

Safe sleeping practices	

  Sugary drinks	

  Physical activity and  exercise	

  Parenting advice	

  Developmental milestones	

   Other: 	
Care provided as part of health check (eg immunisations, medication review, investigations requested) 
<<Care provided as part of the health check(imms etc)>> 	
Identified needs and plan (including new diagnoses)
<<Identified needs and plan (incl new diagnosis)>>	
Follow-up: Consider what follow-up appointments 
can be made at the time of the health check	Reminder: MBS follow up items for clients at risk of or with chronic disease are available to support follow-up of health checks	
Referrals and appointments, for example:
Who	<<Add all details of follow up referrals & appointments>>
When	

GP follow-up		

Aboriginal and/or Torres Strait Islander Health Worker follow-up		

 Aboriginal and/or Torres Strait Islander Health Practitioner  follow-up		

Practice nurse follow-up		

Child health nurse		

Dentist		

Paediatrician		

Audiology		

Speech pathology		

Mental health		

Parenting programs/support services		

Early intervention (development) services		

Other:		
Has a Shared Health Summary been uploaded to My Health Record for this patient? <<Health Summary been sent to My Health Record?>>	
<<Recalls entered>> Recalls entered (eg clinical review including review of results, immunisations, investigations)	
Parent/patient actions: <<Parent/patient actions>>	
Parent/carer has been offered a copy of this health check including details of follow-up and future appointments  <<Parent/carer offered a copy of health check?>>	

Health check claimed (PI 03)
If you would like to provide feedback on this template, please contact © The Royal Australian College of General Practitioners June 2020
This resource is provided under licence by the RACGP. Full terms are available at www.racgp.org.au/usage/licence 
We acknowledge the Traditional Custodians of the lands and seas on which we work and live, and pay our respects to Elders, past, present and future.