ࡱ> oqn` jbjb n|c|c   8<(l 4!0bbbbt<? A A A A A A ,d"R$m C"CCm C  bbU CCCC lb b? C    C? CCj , C CCC!04!Cf%Cf%CC Pd PProfile: Health Behaviours To assist workers/practitioners to screen for harmful health behaviours.Consumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label here Nutritional Risk Screening Tool  FORMCHECKBOX  Obvious underweight  frailty?  FORMCHECKBOX  Unintentional weight loss?  FORMCHECKBOX  Reduced appetite or reduced food and fluid intake?  FORMCHECKBOX  Mouth or teeth or swallowing problem?  FORMCHECKBOX  Follows a special diet?  FORMCHECKBOX  Needs assistance to shop for food?  FORMCHECKBOX  Needs assistance to prepare food?  FORMCHECKBOX  Needs assistance to feed self?  FORMCHECKBOX  Obvious overweight affecting life quality?  FORMCHECKBOX  Unintentional weight gain?  FORMCHECKBOX  No risk identified OUTCOME: YES to one or more questions means that nutritional risk exists and a referral should be discussed. General Health Assessment Have you had a general health assessment in the last 2 to 5 years?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, when?  FORMTEXT       If no, discuss referral to a General Practitioner.Smoking  FORMCHECKBOX  Never smoked  FORMCHECKBOX  Has quit smoking  FORMCHECKBOX  Currently smokes If quit, record when  FORMTEXT       Discuss referral if currently a smoker Alcohol How often do you have a drink containing alcohol?  FORMCHECKBOX  Never  go to next section  FORMCHECKBOX  Monthly  FORMCHECKBOX  Once a week  FORMCHECKBOX  2 to 4 times per week  FORMCHECKBOX  5+ per week How many standard drinks do you have on a typical day when you are drinking?  FORMTEXT       How often do you have more than 6standard drinks on one occasion?  FORMCHECKBOX  Never go to next section  FORMCHECKBOX  Monthly  FORMCHECKBOX  Once a week  FORMCHECKBOX  2 to 4 times per week  FORMCHECKBOX  5+ per week Discuss referral if alcohol consumption is an issue.Physical Activity Would you accumulate 30 minutes or more of moderate intensity physical activity on most days of the week?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Discuss referral if no. Physical Fitness During the past 4 weeks, what was the hardest physical activity you could do for at least 2 minutes?  FORMCHECKBOX  Very heavy (eg run, fast pace; carry a heavy load upstairs or uphill of 25lbs/10kg)  FORMCHECKBOX  Heavy (eg jog, slow pace; climb stairs or a hill at moderate pace)  FORMCHECKBOX  Moderate (eg walk, medium pace; carry a heavy load on level ground 25lbs, 10kg)  FORMCHECKBOX  Light (eg walk, medium pace; carry a light load on level ground (10lbs, 5kg)  FORMCHECKBOX  Very light (eg walk, slow pace; wash dishes) Consider capacity to undertake activities of daily living and discuss referral if response is  light or  very light . Comments, including other relevant issues:  FORMTEXT       Referral Recommended To:  FORMTEXT       Produced by the Victorian Department of Human Services, 2006This information collected by:HB Page 1 of 1Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign:Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT       Health Behaviours 46.0HJ^`hrt,   V X t v x jhgUj7hgUjhgUj>hgUjhgUj`hgUjhgUjthgU hg5jhgUjhgU hgCJhg46.V,$$Ifa$l ,$Ifl +$Ifl $Ifl $Ifl $Ifl  VXZ|RP<,$Ifl $Ifl kd$$Ifl Fd'd&  t 0'    2q22l2q4 l4alp V ( R ) W |  $Ifl $Ifl Td$If^T`l T$If^T`l   ( ) 7 8 9 R S a b c ) * 8 9 : W X f g h | j3 hgUjhgU hg6jKhgUjhgUjchgUjhgUj{hgUjhgUjhgUjhgUhgjhgU2     * , (*FHJ .xj_ hgUj hgUjhgUmHnHujw hgUj hgUj hgUj hgUjhg6UmHnHuj hg6Ujhg6U hg6hgjhgU/ . 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