ࡱ> ^`]a jbjb11 *H[[ , , , ,  >>>8v<\ P&%l?8[%]%]%]%]%]%]%,'R6*% w"%ww%7$, , ] &7$7$7$w, l [%7$  , , , , w[%7$7$ , 7$ S>u!7$7$$ &0P&7$*7$*7$7$ D > >Profile: 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 Oral Health Have you had a dental check-up in the last 3 years?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Estimated date of last check-up?  FORMTEXT       If no, discuss referral to a Dental Clinician. Alcohol When was the last time you had more than (if female) 4 drinks OR (if male) 6drinks, in one day?  FORMTEXT       If response is any time in the past 3 months consider further screening on alcohol and/or referral. Gambling Have you ever had an issue with your gambling?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, consider referring to local Gamblers Help provider.Physical Activity Would you accumulate 30 minutes or more of moderate intensity physical activity on most days of the week?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, discuss referral 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, 2009This 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,Z   V X t j7hwwUjhwwUjh0PhwwU h0Phwwj>hwwUjhwwUj`hwwUjhwwUjthwwU hww5jhwwUjhwwU hwwCJhww26.V ,$$Ifa$,$If+$If$If$If$If VXZ|RPF@2T$If^T`$If $Ifkd$$Ifl Fd'd&  t 0'    2l2l2q24 l4alp V ( R ) V {  , & $Ifx$Ifx$&dIfP$If$IfTd$If^T`T$If^T`t v x  ( ) 7 8 9 R S a b c ) * 8 9 : V W e f g { h0Phww6jKhwwUjhwwUjchwwUjhwwUj{hwwUjhwwUjhwwUjhwwU h0Phwwjh0PhwwUjhwwU/      ( * &(DFHl  yjw h0PhwwUhPhww6j hwwUj hwwUj hwwU jh0PhwwUmHnHuj h0PhwwUh0Phww6j3 hwwU h0Phwwjh0PhwwUjhwwU*&l &.V;Dt x$Ifgdwwx$&dIfPgdww $Ifgdww d$Ifgdww$&dIfP$IfTx$If^T` .0DFHRTV;tu򽲫wlj hwwUjG h\hwwU h0Phww jh\hwwUmHnHuj h\hwwU h\hwwjh\hwwUh0Phww0J.B*phj_ hwwUj hwwU"jh0Phww0J-B*Uphh0Phww0J-B*ph&\]klmvw)*+78FGHĹĮĹģěĹĐĹąĹzĹoĹjhwwUjshwwUjhwwUjhwwUhPhww6jhwwUjhwwUjh0PhwwU h0Phwwhww0J.B*phh0Phww0J-B*ph"jh0Phww0J-B*Uphj/hwwU'\7Zkd$$IfqF 4'   '6    4 qaT$If^T`$If$If $If    RThjlvx~NZ\^jlͺŬ͡Ŭ͒̓}tf[jhwwUh"hww5CJOJQJhww5OJQJ hww0Jhww5CJOJQJmH sH hww5CJOJQJmH sH jDhwwUjhwwUmHnHujHhwwUjhwwUhwwh~hwwCJ h0Phww6 h0Phwwjh0PhwwUj[hwwU# z|5]kd$$Ifl''0'64lal]kd$$Ifln''0'64lal$If dxgdww|~<\XRL%$If#$Ifkd@$$IflF ' 0'6    4 lal$$If$ r  U"$Ifa$  9r $If\^oii"$Ifkd$$Ifl0'  0'624 lalp&(0>@TV^fh|~ȎhwwCJOJQJmH sH jZhwwUjhwwUjzhwwUjhwwUhwwOJQJhww5CJOJQJmH sH jhwwUhwwhww5OJQJjhwwU+keee"$Ifkd$$Ifl0 '  0'622U4 lalpMKIIIIII kd$$IflF '    0'6    22U4 lalp  & ({. 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