Medicare Benefits Schedule (Mbs) Healthy Kids Check - Australia

This fillable "Medicare Benefits Schedule (Mbs) Healthy Kids Check" is a document issued by the Australian Department of Health specifically for Australia residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

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Medicare Benefits Schedule (MBS)
Healthy Kids Check
CHECKLIST
Use of a specific form to record the results of the health assessment is not mandatory but the health assessment should
cover the matters listed in the explanatory notes at www.health.gov.au/mbsonline
Patient’s Name ……………………………………………..…..
Male
Female
DOB:
….../….../…..
Age: …..years …....months
Current contact details
Address ………………………………………………..……….
Phone …………………………………………………..………
….……………………..…………………...…………..…….…..
Parent/Guardian name/s
Healthy Kids Check
Explanation of Healthy Kids Check given
Yes
Consent for Check given
Yes
Date consent was given:
…../…../….
…………………………………………………………..……..….
Signature of Parent/Guardian authorising consent for the
Healthy Kids Check to be undertaken
(the Guide)
Get Set 4 Life – habits for healthy kids
Parent/Guardian advised of the Guide
Yes
Date advised:
…../…../….
………………………………………..……………………..…….
Signature of Parent/Guardian
advised of Get Set 4 Life
Four year old Immunisation
Consent for immunisation given
Yes
Date consent was given:
…../…../….
…………..…………………………..……………………..…….
Signature of Parent/Guardian
If immunisation has previously been given note evidence:
authorising consent for immunisation
Personal Health Record
Yes
Other ……………………………………...…………………….
Vaccine
Batch No.
Date given
Signature / Stamp
Diphtheria, tetanus, pertussis
Poliomyelitis
Measles, mumps, rubella*
*to be given only if MMRV was not given at 18 months
Medicare Benefits Schedule (MBS)
Healthy Kids Check
CHECKLIST
Use of a specific form to record the results of the health assessment is not mandatory but the health assessment should
cover the matters listed in the explanatory notes at www.health.gov.au/mbsonline
Patient’s Name ……………………………………………..…..
Male
Female
DOB:
….../….../…..
Age: …..years …....months
Current contact details
Address ………………………………………………..……….
Phone …………………………………………………..………
….……………………..…………………...…………..…….…..
Parent/Guardian name/s
Healthy Kids Check
Explanation of Healthy Kids Check given
Yes
Consent for Check given
Yes
Date consent was given:
…../…../….
…………………………………………………………..……..….
Signature of Parent/Guardian authorising consent for the
Healthy Kids Check to be undertaken
(the Guide)
Get Set 4 Life – habits for healthy kids
Parent/Guardian advised of the Guide
Yes
Date advised:
…../…../….
………………………………………..……………………..…….
Signature of Parent/Guardian
advised of Get Set 4 Life
Four year old Immunisation
Consent for immunisation given
Yes
Date consent was given:
…../…../….
…………..…………………………..……………………..…….
Signature of Parent/Guardian
If immunisation has previously been given note evidence:
authorising consent for immunisation
Personal Health Record
Yes
Other ……………………………………...…………………….
Vaccine
Batch No.
Date given
Signature / Stamp
Diphtheria, tetanus, pertussis
Poliomyelitis
Measles, mumps, rubella*
*to be given only if MMRV was not given at 18 months
PATIENT HISTORY
Family and environmental factors:
….…………………………………………………….…….………….…
Family relationships
………….………….……………………………………….…….………
….…………………………………………………….…….…….………
Care arrangements
………….………….……………………………………….…….………
….…………………………………………………….…….…….………
………….………….……………………………………….…….………
Medical and social history:
….…………………………………………………….…….…….………
Paediatrician
………….………….……………………………………….…….………
….…………………………………………………….…….…….………
Previous presentations
………….………….……………………………………….…….………
….…………………………………………………….…….……….……
………….………….……………………………………….……….……
Lifestyle risk factors:
….…………………………………………………….…….………….…
Eating Habits
………….………….……………………………………….………….…
….…………………………………………………….…….………….…
Physical activity/inactivity
………….………….……………………………………….………….…
….…………………………………………………….…….………….…
………….………….……………………………………….………….…
PATIENT’S OVERALL HEALTH STATUS
…………………………………………………………………………………………………………………..…………………………
…………………………………………………………………………………………………………………………………..…………
………………………………………………………………………………………………………………………………………..……
……………………………………………………………………………………………………………………………………………..
HEALTH ISSUES IDENTIFIED AND DISCUSSED WITH THE PATIENT’S PARENT/GUARDIAN
…………………………………………………………………………………………………………………..…………………………
…………………………………………………………………………………………………………………………………..…………
………………………………………………………………………………………………………………………………………..……
……………………………………………………………………………………………………………………………………………..
RECOMMENDED INTERVENTION AND/OR REFERRALS
…………………………………………………………………………………………………………………..…………………………
…………………………………………………………………………………………………………………………………..…………
………………………………………………………………………………………………………………………………………..……
……………………………………………………………………………………………………………………………………………..
GP, practice nurse or Aboriginal and Torres Strait
Signature:
Islander health practitioner:
…….………………………..………..…….…………….
…../…../…..
If the check has not been conducted at the
patient’s usual medical practice, a copy of the
record is to be sent to:
……………………………………………………………
……………………………………………………………
…../…../…..
Name of ‘usual’GP/Practice
Parent/Guardian consent to provide copy
EXAMINATIONS AND ASSESSMENT
Measure height and weight
Height: ____________
Weight: ____________
IDENTIFIED ISSUES
ACTION
Check eyesight – may include (but not limited to):
 conducting a visual inspection of the eyes
 using an eye chart if appropriate
 seeking parental/other concerns about vision (eg. amblyopia, squint, infection, injury)
 questioning family history of eyesight problems
 referring the child to an optometrist for an eyesight assessment if appropriate
IDENTIFIED ISSUES
ACTION
Check hearing – may include (but not limited to):
 conducting an ear examination
 seeking parental/other concerns regarding the child’s hearing or listening, following instructions or language
 questioning any history of ear infections, ear discharge, recurrent or chronic otitis media
 referring the child to an audiologist for a hearing assessment if appropriate
IDENTIFIED ISSUES
ACTION
Check oral health – teeth and gums (a potential tool could include Lift the Lip)
questioning whether the child has visited the dentist
questioning how often the child brushes their teeth
IDENTIFIED ISSUES
ACTION
Question toilet habits – may include (but not limited to):
 questioning whether the child needs assistance or can use a toilet independently
 questioning whether the child is a bed wetter
IDENTIFIED ISSUES
ACTION
Note known or suspected allergies
IDENTIFIED ISSUES
ACTION
ADDITIONAL MATTERS FOR CONSIDERATION
The health check may include the following matters, at the discretion of the GP/Practice nurse/Aboriginal and
Torres Strait Islander health practitioner and according to his or her clinical judgement. It may be useful to refer
to the patient’s State/Territory personal health record and the Guide.
General wellbeing:
Discuss eating habits – may include (but not limited to):
discussing the child’s appetite
questioning about the variety of foods the child eats
discussing the frequency of consuming processed foods
IDENTIFIED ISSUES
ACTION
Discuss physical activity – may include (but not limited to):
discussing the time spent in active or energetic play
discussing the time spent in sedentary activities
IDENTIFIED ISSUES
ACTION
Question speech and language development – may include (but not limited to):
 seeking parent/guardian concerns about:
- the number of words their child uses or their understanding of directions
- whether their child speaks clearly and takes an active part in conversations
IDENTIFIED ISSUES
ACTION
Question fine and gross motor skills – may include (but not limited to):
. picking up small objects
. drawing without scribbling
. walking, running, jumping, hopping, climbing stairs
. riding a tricycle
IDENTIFIED ISSUES
ACTION
Question behaviour and mood – may include (but not limited to):
. sleeping
. social and emotional well-being
. energy levels
. ability to separate from main carer
IDENTIFIED ISSUES
ACTION
Other examinations considered necessary by GP/practice nurse/Aboriginal and Torres Strait Islander
health practitioner
EXAMINATION
IDENTIFIED ISSUES
ACTION

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