Welsh Health Check for Adults with a Learning Disability and on the Social Services Register
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1 Welsh Health Check for Adults with a Learning Disability and on the Social Services Register M Kerr, RG Jones, M Hoghton, H Houston, J Perry. AJ Thapar & J Tomlinson Date: Name: Marital status: Date of Birth: Ethnic origin: Sex: Address: Tel Next of Kin Tel Principal Carer: Tel Key Health and Social Care Contacts: Consent to share the review with Carer? Consent to share the review with other named relevant professionals? Names of other individuals to whom the review should be sent: This is a good time to ask the carer, person with a learning disability if they have any specific concerns or issues they wish to cover whilst performing the health check Weight (kg/stone) Blood Pressure Smoke (per day) Body Mass Index (weight in kg / height in m 2 ) & random Blood glucose if indicated Height (meters /feet) Urine Analysis Alcohol (units per week) Cholesterol has been performed if indicated
2 Immunisation People with learning disability should have the same regimes as others and the same contraindications apply. A high risk of hepatitis b has been seen in population of individuals with learning disability Has the patient completed a full course of currently recommended vaccinations? If, has the patient been offered the recommended top up vaccinations? Is the patient included in the annual influenza vaccination programme? / contraindicated Screening uptake Where screening cannot be performed due to refusal it can be helpful to support from the community learning disability teams to support the individual through the procedures Cervical Cytology People with a learning disability have same indications for cervical cytology as others. te: Smear could be declined by patient Is a smear indicated? If yes when was last smear? When is next due? Date: Mammography uptake This should be arranged in line with national screening programme and as per local practice. Is mammography indicated and has it been offered? Performed? Declined Bowel Cancer uptake This should be arranged in line with national screening programme and as per local practice. Indicated and offered? Performed? Declined Aortic aneurysm uptake This should be arranged in line with national screening programme and as per local practice. Indicated and offered? Performed? Declined Chronic Illness Does your patient suffer from any chronic illness?
3 Systems Enquiry Respiratory Be especially concerned if frequent chest infections as these can indicate that swallowing is impaired and referral needed Persistent cough Haemoptysis Abnormal sputum Wheeze Dyspnoea Cardiovascular system Chest pain Swelling of ankles Palpitations Paroxysmal nocturnal dyspnoea Cyanosis Abdominal Be aware of possibility of unrecognised reflux oesophagitis as a cause weight loss, sleep disturbance or dyspepsia Constipation Weight loss Diarrhoea Dyspepsia Melaena Rectal bleeding Faecal incontinence Feeding problems C.N.S. for epilepsy see below Faints Parasthesia Weakness Genito-urinary Dysuria Frequency Haematuria Urinary Incontinence If has M.S.U. been done Have other investigations been considered? Gynaecological Dysmenorrhoea Inter menstrual bleeding PV discharge
4 Is patient post menopausal? Contraceptives Needed Used te: Oral, Intra-uterine device, Depot, Transdermal, Subcutaneous, Diaphragm, Contraceptive sponge, contraception Other te: e.g. PMT, pregnancy Epilepsy te: Consider specialist review if no review in last 3 years Date of last specialist appointment: Less than 3 years Greater than 3 years Type of fit: Focal seizures: simple partial, complex partial or secondary generalised Generalised seizures: absence seizures, myoclonic, clonic, tonic, tonic-clonic or atonic Unclassified seizures Frequency of seizures (fits/month) Over the last year have the fits Antiepileptic medication Worsened Remained the same Improved Name Dose/frequency Levels (if indicated) Side effects observed in the patient Presence of Behavioural disturbance te: Behavioural disturbance in people with a learning disability is often an indicator of other morbidity. For this reason it is important to record it as it can point to other morbidity. The presence of behavioural or emotional change when physical illness has been excluded warrants referral to learning disability services Has there been a change in behaviour since the last review: eg aggression, self injury, over-activity. Are you aware of any risk or change in the level of risk to the patient or others: If yes, has this been communicated to key health and social care professionals
5 Physical Examination General appearance Are there any abnormal physical signs or key negative findings. Cardiovascular System Are there any abnormal physical signs or key negative findings Pulse (beats/min) Blood pressure Ankle Oedema Heart sounds (describe) Respiratory system Are there any abnormal physical signs or key negative findings Abdomen Are there any abnormal physical signs or key negative findings Dermatology Any signs or symptoms Diagnosis Breast Are you aware of any breast symptoms or signs If yes, please indicate what action has been taken:
6 te: If no, please indicate why (e.g. consent issues) Testis Has an examination of testis been performed Central Nervous System te: It is often difficult and not relevant to perform a full neurological examination, however, people with a learning disability are particularly prone to abnormalities in vision, hearing and communication a change in function would suggest further investigation is necessary Presence of vision difficulties Does the patient appear to have eyesight problems e.g. eye rubbing? rmal vision? te: include normal vision corrected with glasses/ contact lenses Minor visual problem? Major visual problems? te: include registered blind Is the carer/key worker concerned? Recommend the carer takes the patient to an optometrist Is there a cataract? Presence of hearing difficulties rmal hearing? Minor hearing problem? Major hearing problem? Is the carer/ key worker concerned? Does he/she wear a hearing aid? te: if no has he/she been fitted for a hearing aid? Any wax? Does your patient see an audiologist? Other investigation Has the patient ever had a hearing screen? For those aged 40 and over, has the patient had a hearing screen within the past 3 years? For those with Down s syndrome (regardless of age), has the patient had a hearing assessment with the past 3 years? Presence of communication difficulties Does your patient communicate normally? Does your patient communicate with aids? te: e.g. writing pad, signing Does your patient have a severe communication problem? Does your patient see a speech therapist?
7 Where communications problems exist have practice staff been made aware & medical record tagged? Presence of mobility difficulties Is your patient fully mobile? If no, please specify nature and severity of mobility loss such as presence of contractures e.g. uses a wheelchair, walking stick, walking frame, crutches, splints, surgical boots Has there been any change in mobility and dexterity of patient since the last review? If yes, please specify: Other Investigations Are there any further investigations necessary? If yes please indicate Syndrome Specific Check te: Certain syndromes causing learning disabilities are associated with increased morbidity for this reason it is important to record: Is the cause of learning disability known? If yes, what is it? Has the patient had a genetic investigation? Result? If your patient has Down s syndrome he/she should have a yearly thyroid profile Has this been done? Medication Review Drug Dose Side Effects Levels (if indicated)
8 Please list the key findings from the medication review. Actions Please list the actions that have arisen as a result of the medication review and indicate how these have been dealt with. Every year the patient should have a review by a dental practitioner has this been done? Every year the patient should have a review by an optometrist has this been done? Has a summary letter with appropriate responses been sent to the patient or carer? Has a copy of the letter been sent to the community learning disability team if involved?
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Metropolitan Police Friendly Society Berwick House, 8-10 Knoll Rise, Orpington, Kent, BR6 0EL Despatch: MPFS Orpington - Phone: 01689 891454 - Metphone: 2 Email: enquiries@mpfs.org.uk - Web: www.mpfs.org.uk
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Patient Demographics Sheet
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Health Information Form for Adults
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OrthoVirginia Registration Information 2016
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Plano Heart Center, P.A.
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PREVENTIVE HEALTHCARE GUIDELINES INTRODUCTION
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INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM
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Princeton and Rutgers Neurology, P.A. A Center Of Excellence
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PEDIATRIC MEDICAL HISTORY FORM
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Life Insurance Application Form
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Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081
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