A good health check:
•	is useful to the patient
•	identifies health needs including patient health goals and priorities
•	supports patients to take charge of their health and wellbeing
•	provides a framework for primary and secondary disease prevention through healthcare advice, risk assessment and other measures
•	is provided by the regular healthcare provider
•	includes a plan for follow-up of identified health needs, priorities and goals.
Disclaimer: This is an example health check template that includes recommended core elements and is intended for use as a general guide only. Health checks should always be completed based on clinical judgement of what is relevant to individual patients and settings. Adaptation to local needs and priorities is encouraged, with reference to current Australian preventive health guidelines that are culturally and clinically suitable to Aboriginal and Torres Strait Islander needs, evidence-based and generally accepted in primary care practice, for example:
•	National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, 3rd edition, The Royal Australian College of General Practitioners (RACGP) and National Aboriginal Community Controlled Health Organisation (NACCHO)
•	CARPA standard treatment manual, 7th edition, Central Australian Rural Practitioner’s Association (CARPA). 
Where an individual practitioner or service has skills and capacity to provide culturally safe healthcare, the range of elements in the health check, and use of clinical screening and assessment tools, may be extended.
Key: 
•	Relevant to nKPIs
•	Relevant to QI PIP 
About the health check 	Yes	No	N/A		
Eligible for health check (not claimed 715 or 228 in past nine months):				Date of last health check: 	
Consent	
Consent given after discussion of process and benefits of a health check:  					
Consent given for sharing of information with relevant healthcare providers:				Who/details:	
Date:	Doctor:	Nurse:	
Aboriginal and/or Torres Strait Islander Health Worker / Health Practitioner:	
Location of health check:	

 Clinic	

 Home	

 School	

 Other: 	
Patient details	
Name: 	Date of birth: 	Age: 	Gender: 	
Aboriginal and/or Torres Strait Islander status:	

 Aboriginal	

 Torres Strait Islander	

 Aboriginal and Torres Strait Islander	
Address:	
Home phone: 	Mobile phone:	
Emergency contact:	Relationship to patient:	Emergency contact phone:	
Medicare number:	Reference number:	Expiry: 	
Pension/Health Care Card number:	
	Yes	No	N/A		
Registered for Closing the Gap 
PBS Co-payment Measure (CTG):					
Registered for National Disability 
Insurance Scheme				Yes, number:	
Do you have children?				Number of children: 	Number of children in your care: 	
Are you responsible for caring for 
someone else?				Details:	
Are name and contact details of other key providers (eg case workers, support services) up to date?				Details:	

Assessment	Health priorities, actions and follow-up	
Current health/patient priorities
What are the important things for you in this health check today? 
Details: 
Is there anything you are worried about?
Details:
Do you have any specific health goals? Is there anything in particular about your health and wellbeing that you would like to improve?
Details: 		
Medical history and current problems		
 Diabetes
 Hypertension
 Myocardial infarction
 Stroke
 Kidney disease
 Hearing impairment
 Epilepsy	 Asthma
 COPD
 Rheumatic heart disease
 HBV
 Significant head trauma
 Mental health		

 Other relevant medical history, operations, hospital admissions, etc
Details:		
Regular medications: check if still required, appropriate dose, understanding of medication and adherence		

Do you take any regular medications (prescribed, over-the-counter, traditional, complementary and alternative)?

 None  Yes, up to date in health record
 Understanding and adherence checked		
Allergies/adverse reactions 		

 Up to date in health record		
Relevant family history (including diabetes, heart disease, cancer, mental health)		
Details: 		
Social and emotional wellbeing 
General 
Have there been any particular stressful life events that are impacting on you/your health lately?

Yes  No     Details:
Consider conversation about social connection, which could include questions about sports/hobbies/clubs/other activities
Details:		
Home and family
Who do you live with?
Details:
Do you have stable housing?

Yes  No     Details:
Do you feel safe at home? 

Yes  No     Details:		
Learning and work 
Are you studying?
Yes  No     Details: 
Are you working?   Yes    No   N/A
Details (occupation including occupational hazards, study, training, disability, etc): 		
Mood 
How have you been feeling lately? 
Details: 
If indicated, ask about depression (consider screening tools, eg aPHQ-9, K5 or K10) and complete risk assessment.
Details: 
Explore other mental health concerns as indicated.
Details: 		
Healthy eating		
Do you have any worries about your diet or weight?

Yes  No 
Details:
Document conversation about age-appropriate healthy eating, which could include:
•	current diet including food and drinks
•	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)
Details:
Are there any issues about availability of food? 

Yes  No     Details: 		
Physical activity, exercise and screen time
Do you have any worries about physical activity or screen time? 

Yes  No     Details: 
Document conversation about recommendations re physical activity, exercise and screen time.
Details:		
Substance use, including tobacco
Smoking (QI M2, PI 09, PI 10)		
Never smoked
Ex-smoker
Current smoker	
Quit <12 months
How many? 	
Quit ≥12 months
How long? 		
Wants to quit
Other tobacco use
Environmental exposure to tobacco smoke (home, car, etc)
Alcohol and other substance use (QI M2, PI 16)
Quantity and frequency of:
•	alcohol 
•	caffeine (coffee, soft drinks, iced coffee)
•	cannabis/yarndi/gunja
•	other substance use: IVDU, methamphetamine, other stimulants, opiates, solvents, other
Details: 		
Gambling
Have you or someone close to you ever had issues with gambling? 

Yes  No     Details:		
Genitourinary and sexual health
Is there anything that you are worried about in relation to 
your sexual health? 

Yes  No     Details: 
Cervical screening (QI M9, PI 22)			
 Offered
 Not required
 Next due:	 Declined
 Up to date		
Details:
Consider discussing as relevant to age/sex/gender:
•	contraception
•	menstruation
•	sexually transmitted infection symptoms and screening
•	blood-borne virus screening
•	continence
•	menopause
•	erectile dysfunction		
Immunisation (eligibility for funded 
vaccines may vary across jurisdictions) 
Check recommended primary vaccinations completed and provide catch-up if required
Immunisations up to date and recorded on Australian Immunisation Register (as per Australian Immunisation Handbook)? 

Yes  No     Immunisations due: 
Vaccines given today recorded on Australian Immunisation Register? 

Yes  No     Details: 		
Eye health
Is there anything that you are worried about with your vision? 

Yes  No     Details: 
Eye examination	
Visual acui

ty  R       L

Trachoma check (endemic areas) 
R  Trichiasis	Corneal scarring
L  Trichiasis	Corneal scarring		
Ear health and hearing
Is there anything that you are worried about with your hearing? 

Yes  No     Details: 
Last hearing test (audiology): 
Ear examination
Otoscopy findings (may be more than one of these): 		
Left ear
 Clear and intact
 Dull and intact
 Discharge
 Retracted
 Unable to view eardrum
 Wax
 Other: 	Right ear
 Clear and intact
 Dull and intact
 Discharge
 Retracted
 Unable to view eardrum
 Wax
 Other:		
Oral and dental health
Is there anything that you are worried about with your teeth? 

Yes  No     Details: 
Last dental checkup: 
Teeth and mouth check 
Examination findings: 
Document conversation about oral health and care of teeth
Details: 		

Assessment	Health priorities, actions and follow-up	
Examination		
Height:
Weight (QI M3):
BMI:	Waist circumference:
Blood pressure:
Heart rate and rhythm:		
Absolute cardiovascular risk calculation (QI M8, PI 21)
Cardiovascular risk calculated: https://auscvdrisk.com.au/risk-calculator
Result: 		
Investigations 
•	Full blood count
•	HbA1c or blood glucose level
•	Serum lipids
•	Kidney function including eGFR
•	Liver function tests
•	ACR
Chlamydia, gonorrhoea: age ≤30 years, first void urine (male and female) and/or endocervical swab or self-administered vaginal swab (female) or throat and anal swab (men who have sex with men [MSM])
Syphilis (endemic areas, MSM, others at high risk)
Trichomoniasis: age ≤30 years, male and female, remote areas and other endemic areas, first void urine and/or endocervical swab or self-administered vaginal swab
Blood-borne virus screening:
•	HBV if status not known/not recorded on file
•	HCV, if risk factors
•	HIV, if risk factors		

Finalising the health check	
Patient priorities and goals: What does the patient say are the important things that have come out of this health check?
	
Brief intervention: Advice and information provided during health check, for example:	

 Healthy eating 	

 Screen use	

 Physical activity and exercise	

 Mental health and wellbeing	

 Carer support	

 Safety/risky
     behaviours	

 Smoking
     cessation	

 Substance use/harm   
     minimisation	

 Safe sex/contraception	

 Oral and dental
     health	
Other:	
Care provided as part of the health check (eg immunisations, medication review, investigations requested)
	
Identified needs and plan (including new diagnoses)
	
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	
When	

 GP follow-up		

 GP review of results of investigations		

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

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

 Practice nurse follow-up		

 Dentist		

 Medication review		

 Smoking cessation		

 Audiology		

 Dietician		

 Physiotherapist or exercise program		

 Parenting programs/support services		

 Social and emotional wellbeing/mental health		

 Other: 		
Recalls entered (eg clinical review including review of results, immunisations, asthma plan/cycle of care, diabetes cycle of care, care plan review, cervical screening, investigations)
	
Patient actions
	
Patient has been offered a copy of this health check including details of follow-up and future appointments 	

 Yes, copy taken	

 Yes, but declined	

 Not offered. Plan to follow up and offer at a later date	
Health check claimed (PI 03)
If you would like to provide feedback on this template, please contact aboriginalhealth@racgp.org.au
© 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.