ࡱ> XZUVW` >jbjb |c|cDL7778,88LLW2;AAAAC FG,RYHB@CHHHAAHHHHAAH$4HHHhJ ; 7Hnl'0W H HLLD%7dLL7Functional Assessment Summary This supplementary template is sent with referrals that occur following assessment of the clients functional abilities and need for assistance. Theassessing agency may attach additional assessment summaries covering other domains ofclient need that are relevant to the referral.Consumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label hereRating of Functional Abilities Notes on ratings: Tick one response for each activity (example: housework, transport, shopping etc.) Rate what the person is currently capable of doing rather than what they actually do. In addressing capability for any item, take into account not only physical function but also cognition (such as problems caused by dementia or an intellectual disability) and behaviour (such as unpredictable challenging behaviour). People able to complete a task only with verbal prompting should not be rated as independent. If unable to rate an activity, leave it blank. Assessment notes: Use the notes section to describe clients specific need for assistance as well as other factors impacting on level and type of need e.g. use of aids and equipment/home modifications; assistance provided by carers/other agencies. ActivityRating ((one)Domestic Care1. Housework FORMTEXT  Can maintain house without help or supervision (including laundry) FORMTEXT  Needs some help or supervision FORMTEXT  Completely unable to do housework2. Transport FORMTEXT  Without help (drives own car, travels independently on public transport or taxis) FORMTEXT  With some help (need someone to help or accompany when traveling) FORMTEXT  Completely unable to travel (unless arrangements are made for a specialized vehicle like an ambulance)3. Shopping (assuming client has transport) FORMTEXT  Can take care of all shopping needs FORMTEXT  With some help (need someone to go with client on all shopping trips) FORMTEXT  Completely unable to do any shopping4. Meal Preparation FORMTEXT  Without help (incl planning/preparing/cooking, adequacy of meals and serving) FORMTEXT  With some help FORMTEXT  Completely unable to do any meal preparation, serving or manage nutrition5. Taking Medications FORMTEXT  Without help (in the right doses at the right time) FORMTEXT  With some help (e.g. if someone prepares or reminds client) FORMTEXT  Completely unable to take own medicines without help6. Handling Money FORMTEXT  Without help (writing cheques, paying bills, banking, keeping track of finances) FORMTEXT  With some help (manage day-to-day buying but need help with chequebook and paying bills) FORMTEXT  Completely unable to handle money7. Telephone FORMTEXT  Without help (making and receiving phone calls & incl use of assistive devices) FORMTEXT  With some help FORMTEXT  Completely unable to use the telephone8. Mobility/Walking FORMTEXT  Without help, except for the use of a cane FORMTEXT  With some help from a person (physical or verbal), or with the use of a walker or crutches. If in a wheelchair, tick this rating if the person manages independently including cornering. FORMTEXT  Completely unable to walk. If in a wheelchair, tick this rating if the person is not independent but must be pushed.9. Mobility: bed/chair transfers FORMTEXT  No help needed FORMTEXT  Needs some help FORMTEXT  Unable to manage  no sitting balanceAssessment notes  Domestic Care:  FORMTEXT       Produced by the Victorian Department of Human Services, 2006This information collected by:Supplementary Form Page 1 of 2Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign: Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT       Functional Assessment Summary This supplementary template is sent with referrals/ feedback that occur following assessment of the client s functional abilities and need for assistance. The assessing agency may attach additional assessment summaries covering other domains of client need that are relevant to the referral.Consumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label here ActivityRating ((one)Personal Care 10. Self-care screening questionDoes the client need assistance with any areas of personal care/self care, such as bathing, dressing, eating toileting, managing incontinence? FORMTEXT  No (( skip the personal care items and go to Q16) FORMTEXT  Yes (( proceed to the following personal care items)11. Bathing FORMTEXT  Without help (include in and out of shower or bath and washing unsupervised) FORMTEXT  With some help (e.g. need help getting in or out of the bath) FORMTEXT  Completely unable to bathe without help12. Dressing FORMTEXT  Without help (incl buttons, zips, laces) FORMTEXT  With some help (e.g. help with buttons etc. but can put on some garments alone) FORMTEXT  Completely unable to dress13. Eating  FORMTEXT  Without help FORMTEXT  With some help (e.g. help cutting up food, spreading butter, pouring drink) FORMTEXT  Completely unable to eat without help (e.g. spoon feeding)14. Toilet use FORMTEXT  Without help (includes on and off, dressing and cleans self) FORMTEXT  With some help  FORMTEXT  Completely unable to manage toiletting without help15. Continence (bowels and/or bladder) FORMTEXT  Completely continent including self management of catheter or ostomy. Rate based on last week. FORMTEXT  Occasional incontinence (less than once per day) FORMTEXT  Incontinent (no control or daily episodes of incontinence)Assessment notes  Personal Care/Self Care:  FORMTEXT      ActivityRating ((one)Communication, Cognition & Behaviour16. Communication (Need for assistance with understanding or making oneself understood by others) FORMTEXT  No assistance required including independent use of aids and equipment such as hearing aids or speech aids. Do not indicate use of interpreters here. FORMTEXT  Some assistance required (e.g. if person sometimes or often misses the speaker s intent, or needs prompting to find words or finish sentences.) FORMTEXT  Assistance always requiredAssessment notes  Communication:  FORMTEXT      17. Memory problems or confusion FORMTEXT  No  FORMTEXT  Yes18. Behavioural problems  FORMTEXT  No FORMTEXT  Yes (e.g. aggression, wandering or agitation)Assessment notes  Cognition and Behaviour:  FORMTEXT      Assessment details Date of assessment: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Assessor Name:  FORMTEXT       Other comments, e.g. assessment tools used, location of assessment, other assessment summaries attached:  FORMTEXT       Produced by the Victorian Department of Human Services, 2006This information collected by:Supplementary Form Page 2 of 2Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign: Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT       Functional Assessment Summary Functional Assessment Summary 9:IJTU *,DFZ\dnp    (     䡕xh85B*ph$ jh85B*CJOJQJphh85B*CJph h85CJ h86jBh8Ujh8Ujbh8Ujh8Ujvh8U h85jh8Ujh8Uh8/89C* R $$Ifa$l ;$Ifl 9$Ifl $Ifl $Ifl $Ifl  <>>>>R T . 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