ATT NURSING STAFF AND HEALTH CARE WORKERS

How to complete this health assessment: 
Before commencing this template, please complete/update the following to allow for auto entry into the template:
1.	Full observations including BP, Waist, Height, Weight 
2.	Smoking status 
3.	Alcohol intake 
4.	Family History
5.	Allergies
6.	Medical History 
7.	Medications if needed 
8.	AUSDRISK Score: link here or use in the Best practice software
Highlighted yellow indicates where you need to edit for this health assessment.
Remove tasks for the patient if they are irrelevant.
Links in the form are interactive and take you to website and patient information for you to print if relevant. 

Type 2 Diabetes Risk Health Assessment for 40-49 year old	

Patient’s Name: <PtFullName>	Date of Birth: <PtDoB>	
Phone: <PtPhoneMob>		

Details of Patient’s Usual GP:	
<DrDetails>	

ELIGIBILITY FOR TYPE 2 DIABETES RISK EVALUATION
Patient aged 40 – 49 years?		<PtAge>	
Patient has completed Australian Type 2 Diabetes Risk Assessment Tool	Yes	
AUSDRISK Score- >12, under 12 cannot complete health assessment	See score below	
Diabetes status - Negative	No	
No recent health assessment in the last 3 years – No 	No	

RISK ASSESSMENT SCORE ON THE AUSTRALIAN TYPE 2 DIABETES RISK ASSESSMENT TOOL 
Score:	<Risk Assessment Score>	Date: <Date risk assessment completed>
	12 or more = high risk of developing diabetes 
	16-19 approximately one person in every seven will develop diabetes within 5 years
	20+ approximately one person in every three will develop diabetes within 5 years
	If score under 12? stop this assessment, it cannot be claimed 

PAST MEDICAL HISTORY
<PMHActive>	MEDICATIONS 
<CurrentRx>	
FAMILY HISTORY
<FamilyHx>	ALLERGIES
<Reactions>	

TYPE 2 DIABETES RISK EVALUATION 701, 703, 705, 707	

Risk factors	Patient status	Goals	Discussions with the patient (choose relevant)	
Weight and measurements	Observations: 
<Observations>

Smoking and Alcohol:
Smoking status: <SmkStatus>
Smoking History: <SmkHx>
Vaping:
Alcohol consumption: <AlcHx>
	Recommended:
Ideal BMI: 20-25 Kg/m2
Ideal waist measurement:
Asian or ATSI descent: Women less than 80cm and Men: less than 90cm
For all others: Women less than 88cm and Men: less than 102cm 

Patient’s own ideal goal:
	GP Discussion
4 monthly measurements with practice nurse
Modifying risk factors as below 	
Blood pressure		Ideal blood pressure:
Less than 130/80 mm Hg 

Patient’s own ideal goal:
	Discussion with GP re medications or agents 
Weight loss
Aim for 2.5 hours of exercise per week 
Salt reduced diet to under 4g per day 
Consider the DASH diet approach 
Decrease alcohol. 
Cessation of Smoking
Annual ACR + GFR/EUC if hypertensive	
Smoking		Ideal:
Non-smoker and non-vaping 

Patient’s own ideal goal:
	Quitline 131 848 
Quit smoking app 
Discuss with GP regarding therapy for quitting 	
Alcohol		Recommended:
No more than 2 standard drinks in any one day

Patient’s own ideal goal:
	Get Healthy Service to support reducing alcohol 
Discussion with GP about needing help reducing alcohol 	
Nutrition	Daily Vegetable intake: 
Daily fruit intake: 
Daily bread/rice/pasta intake: 
Daily dairy intake: 
Daily Lean meat intake: 
Daily sugar based treat intake: 
	Recommended daily serves:
Vegetables/legumes: 4-7 serves
Bread/cereals/rice/pasta: 4-6 serves
Fruit: 2-3 serves
Milk/yogurt/cheese: 2-3 serves (low fat)
Lean meat/fish/poultry/eggs: 1-2 serves

Patient’s own ideal goal:
	Get healthy service
The Australian Guide to Health Eating
Discussion with Dietitian 	
Exercise	Current exercise weekly routine: 	Ideal:
Exercise at least 30 minutes walking or equivalent 5 or more days per week

Patient’s own ideal goal:
	Get healthy service
Engage in local fitness group- fit this in Active and Healthy
Discuss with GP on concerns or questions regarding exercise