Taking a medical history
Assess the person’s capacity to provide an accurate history—information may be needed from other sources; see Obtaining information from other sources.
For advice on communicating with a person with developmental disability during a consultation, see here. For tools to assess pain or distress in people with communication difficulty, see Pain assessment tools.
Consider using a disability health assessment templateto prompt information gathering. These are specific to people with developmental disability, and help to identify health problems that are often missed or misdiagnosed in this group; see also Commonly missed health problems in people with developmental disability.
Medicare items may apply for health assessments and care planning for people with intellectual disability. See the Australian Government Department of Health Medicare Benefit Schedule Health Assessment for people with intellectual disability fact sheet.
[NB1]
Patient details (essential)
cause of disability (if known)
preferred effective communication method
neuromuscular, cognitive and sensory functioning
capacity for decision making, support needed to participate in decisions, and responsible person or medical decision maker (if applicable)
current medications
Additional information (if available) [NB2]
mealtime plan (detailing oral intake and mealtime assistance needs)
bowel care plan
seizure charts
behavioural records, including a behaviour support plan [NB3]
current NDIS plan
past specialist assessments
immunisation history
Personal history
family involvement
preferences (eg activities, support person, end-of-life plans [eg advance care plan])
past residential information
NB1:The type of information and level of detail will vary depending on the aetiology and type of disability, and the clinical presentation.
NB2: Consider using a Comprehensive health assessment template to prompt information gathering.
NB3: Especially recent changes in behaviour (eg what, when, where, with whom the changes occur).