Beruflich Dokumente
Kultur Dokumente
Male
Female
DOB: ../../.. or
Patients Name ..
Age: . (45-49 Inclusive)
Country of Birth:
Patients Occupation: ..
Consent Patient
Yes
Nurse
Yes
No
Yes
No
Yes
No
Type of assessment:
RECOMMENDED INTERVENTION
Date: ../../..
GP: Dr. .
GPs signature .
Date: ../../...
ACTION
RISK FACTORS
ACTION
Cancer
Cardiovascular illness
RISK FACTORS
ACTION
Diabetes mellitus
RISK FACTORS
ACTION
ACTION
RISK FACTORS
ACTION
Arthritis
ACTION
RISK FACTORS
ACTION
Other
ACTION
RISK FACTORS
ACTION
Nutrition
ACTION
Physical inactivity
RISK FACTORS
ACTION
RISK FACTORS
ACTION
Moods
Abnormal
ACTION
Body weight
Waist circumference (if indicated): ...
Weight: Height: BMI:
RISK FACTORS
ACTION
High cholesterol
RISK FACTORS
ACTION
ACTION
RISK FACTORS
ACTION
Urinalysis
ACTION
Tests Ordered
Date: . . . / .. . . /. . . . .
Lipids
Date: . . . / .. . . /. . . . .
Pap Smear
Mammography
Testicular Examination
Prostate Assessment
Date: . . . / .. . . /. . . . .
Date: . . . / .. . . /. . . . .
Date: . . . / .. . . /. . . . .
Date: . . . / .. . . /. . . . .
Other:
Advice and Information to the Patient (including strategies to achieve lifestyle and behaviour changes)
Risk factors identified and discussed with patient