ࡱ> |~{` vjbjb x|c|c   8D> ,.~~~~&`7)d*C-E-E-E-E-E-E-,/R22q-u O+$&O+O+q-O+ ~~W-O+O+O+O+ l~ ~C-O+   O+C-O+O+x , O+ O+O+O+-0,.O+2O+2O+O+ ^d ^Profile: Health Conditions To assist workers/practitioners to screen for consumer s health needs.Consumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label here Overall Health Q1 In general, how would you say your health is?  FORMTEXT       Code:  FORMTEXT    Q2 How much did your health interfere with your normal activities (outside and/or inside the home) during the past 4weeks?(  FORMTEXT       Code:  FORMTEXT    Pain How much bodily pain have you had during the past 4weeks?  FORMTEXT       Code:  FORMTEXT    Hearing How is your hearing (with your hearing aid)?  FORMTEXT       Code:  FORMTEXT   Vision Q1 How is your eyesight for reading (with your glasses)?  FORMTEXT       Code:  FORMTEXT    Q2 How is your long distance eyesight (with your glasses)?  FORMTEXT       Code:  FORMTEXT    Falls Q1 Do you have a fear of falling?  FORMTEXT       Code:  FORMTEXT    Q2 Have you had a fall inside/outside the home in the past 6months?  FORMTEXT       Code:  FORMTEXT   Consider both activities of daily living and need for referral if the consumer has any problems with any of the above. Health Conditions (include all issues eg, allergies, acute medical conditions, disabilities, continence, dental, developmental problems) 1.  FORMTEXT      6.  FORMTEXT      2.  FORMTEXT      7.  FORMTEXT      3.  FORMTEXT      8.  FORMTEXT      4.  FORMTEXT      9.  FORMTEXT      5.  FORMTEXT       10.  FORMTEXT      Current Medications (include prescriptions, over-the-counter and alternate products) 1.  FORMTEXT      6.  FORMTEXT      2.  FORMTEXT      7.  FORMTEXT      3.  FORMTEXT      8.  FORMTEXT      4.  FORMTEXT      9.  FORMTEXT      5.  FORMTEXT       10.  FORMTEXT      Note: Polypharmacy may suggest a medication review is desirable Comments:  FORMTEXT       Referral Recommended To:  FORMTEXT       Produced by the Victorian Department of Human Services, 2006This information collected by:HC Page 1 of 1Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign:Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT       Health Conditions 46 *,DFZ\dnp(tv~      & hEg5B*CJ phjhEgUmHnHujhEgUj>hEgUjhEgUj`hEgUjhEgUjthEgU hEg5jhEgUjhEgU hEgCJhEg36*R+$$Ifa$l +$Ifl *$Ifl $Ifl $Ifl $Ifl  FHtRTVt2 RP<% $Ifl ($Ifl kd$$Ifl Fd'd&  t 0'    2q22l2q4 l4alp & ( * . 0 2 8 <   4 6 8 : N P R \ ^ ` j l n   , . 0 : < > H J L ` b d h j l n | ~ շլզ՛շՐզjhEgUjhEgU hEgCJj%hEgUhEg5B*CJ phjhEgU jhEghEg hEg5jhEgUmHnHujhEgUj9hEgU82 l ~ 6 D  mmT  $Ifl   $Ifl   ($Ifl  ($Ifl  $Ifl  ($Ifl  x$Ifl        * , . 2 4 D F J        jhEgUj_hEgUjhEgUjshEgU hEg5jhEgUhEg5B*CJ phjhEgUmHnHujhEgUhEgjhEgU9 4n  $Ifl   $Ifl   Z$Ifl   ($Ifl   $Ifl  46JLNXZ\fhj~.02<>@JLNbdfjlp^vxj hEgUj hEgUhEgOJQJ hEg6j hEgUj7 hEgU hEg5j hEgUhEg5B*CJ phjhEgUmHnHujK hEgUjhEgUhEg4np^p$Ifl  ddTkd# $$Ifl0'62 2T24 la&(24HJLVX`bvxz "68:jhEgUj hEgUjhEgUjqhEgUjLhEgUjhEgUj hEgUj; hEgUhEgjhEgUjhEgUmHnHu8*$Ifl lkd $$If0'02a*,Z$Ifl lkd'$$If0'02a$Ifl lkd$$If0'02aH$Ifl lkd]$$If0'02a:DFpr (*>@BLNXZnpr|~ *,.8:BDXjxhEgUjShEgUjhEgUjhEgUjBhEgUjhEgUjhEgUhEg6OJQJhEgjhEgUjhEgUmHnHu8HJr"Pxx$Ifl  dlkd$$If0'02aPR$Ifl lkd$$If0'02a $Ifl lkd.$$If0'02a <j$Ifl lkd$$If0'02aXZ\fhrtNbdxz|jlڿڴکښڋڅ|hEg5OJQJ hEg0JhEg5CJOJQJmH sH hEg5CJOJQJmH sH jhEgUjhEgU hEg6jhEgUjhEgUhEgjhEgUmHnHujhEgUjhEgU.jl$Ifl lkdd$$If0'02aN|$Ifl <lkd$$If0'02a3]kd$$Ifl''0'64lal$Ifl ]kd"$$Ifl''0'64laljl>.#$Ifl kd$$IflF ' 0'6    4 lal$$Ifl $ r  U"$Ifa$l  9r $Ifl J_OO"$Ifl kd}$$Ifl0'  0'624 lalp%$Ifl "$8:HJLVX~02@BDv߽߲ߧߜߑ콃hEgCJOJQJmH sH j"hEgUjR"hEgUj!hEgUjf!hEgUhEgOJQJhEg5CJOJQJmH sH jhEgUhEghEg5OJQJjhEgUjvhEgU$JLXBk[[["$Ifl kd^ $$Ifl0 '  0'622U4 lalpBDFHJLprtMKIIIGII& kd2#$$IflF '    0'6    22U4 lalptv ({. 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