ࡱ> a "jbjb11 *x[[. (    h   8Dlh ?4#4#4#4#0(72D{3s>u>u>u>u>u>u>,vARC> 4-\044>; 4#4# F?;;;4 l4# 4#s>;, $P  4s>;; , ; T 7;;\?0?;bD;bD;; h h  h h 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    Chronic Conditions Do you have a diagnosed chronic condition?  FORMTEXT       Code:  FORMTEXT    If yes, list conditions under Health Conditions and consider completing the Health Behaviors profile to identify modifiable risk factors and/or consider referral to chronic disease management and/or lifestyle intervention program. Oral Health Are you currently experiencing any problems with your gums, mouth or teeth? (Example: broken teeth, fillings, bleeding or swollen gums, dentures that fit poorly or cause discomfort).  FORMCHECKBOX  Yes  FORMCHECKBOX  No. If yes, please list under health conditions and consider referral to a dental clinician if the consumer has problems with their oral health and/or has not had a check-up in 3 years.Vision Q1 Do you have difficulty with vision, even with glasses?  FORMTEXT       Code:  FORMTEXT    Q2 Do you have difficulties carrying out your daily activities due to poor vision?  FORMTEXT       Code:  FORMTEXT    Hearing How is your hearing (with your hearing aid)?  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 and/or chronic medical conditions, disabilities, depression, continence, dental, developmental problems) 1.  FORMTEXT      6.  FORMTEXT      2.  FORMTEXT      7.  FORMTEXT      3.  FORMTEXT      8.  FORMTEXT      4.  FORMTEXT      9.  FORMTEXT      5.  FORMTEXT      10.  FORMTEXT       Produced by the Victorian Department of Human Services, 2009This information collected by:HC Page 1 of 2Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign:Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT       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 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, 2009This information collected by:HC Page 2 of 2Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign:Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT           Health Conditions Health Conditions 46 *,DFZ\dnp(Vtv~jhKhONUhKhON5jhKhONU hKhONj>hONUjhONUj`hONUjhONUjthONU hON5jhONUjhONU hONCJhON-6*R +$$Ifa$+$If*$If$If$If$If \"v""RTVt2 RPF8  $If ($Ifkd$$Ifl Fd'd&  t 0'    2l2l2q24 l4alp       & ( * . 0 2 4 6 : 2 4 H J L V X Z d f h | ~   ( * , 6 8 ݯݡ݌݃ujhKhONUhKhONCJ)jhKhONU_HmHnHsHtHj%hKhONUjhKhONUhKhON5j9hKhONUhKhON5CJ hKhONjhKhONU jhKhONUmHnHu.2 h B JL  $IfgdON   $If  ($If $IfgdON $IfgdON $IfgdON  $If ($If x$If8 : D F H \ ^ ` d f h        " 6 8 : > @ B ukhON0J,B*phjhKhONUjhKhONU"jhKhON0J,B*Uph)jhKhONU_HmHnHsHtHhKhON0J,B*ph jhKhONUmHnHujhKhONUjhKhONUhKhON5CJ hKhON$/  &(*>߷ߨߒn`nVhKhON5CJ j[hKhONU jhKhONUmHnHuhKhON5jhKhONU hKhON *hKhON0J,B*phhKhON0J-6B*phjhONUjshONU"jhKhON0J,B*UphhKhON0J,B*ph%jhKhONUmHnHsHtH >@BFHJLT (*,@BDHJLZ\湫湡湓͹}td}ZhkY3hON5CJ j3 hkY3hONCJUhkY3hONCJjhkY3hONCJUhKhONCJj hKhONUhKhON5CJ jG hKhONU hKhONhKhON0J,B*phhKhON5 jhKhONUmHnHujhKhONUjhKhONU#L\dJ  $If  Z$IfgdON  Z$If  ($If  d($IfgdON  $IfgdON ($IfgdON "dfh|~JL`bdnpr|~ǿҮҠǮҖ҈ǮǿҿzǮҖlj hKhONUj hKhONUj hKhONUhKhON5CJ j hKhONU jhKhONUmHnHuhKhON5jhKhONU hKhONj hkY3hONCJUhkY3hONCJjhkY3hONCJU*"h "$&026<>RTV`bjlݽݹݫݝݹ|q|jyhONUjhONUmHnHujhONUjhONUj hKhONUjh hKhONUhONhKhON0J,B*phhKhONOJQJhKhON6 hKhONjhKhONU jhKhONUmHnHu*4$If d,gdON,gdONTkd $$Ifl0'62 2T24 la46d$IflkdT$$Ifs0'02a$Iflkd$$Ifs0'02a&(<>@JLVXlnpz|02ڹڮڣڔڅ hON0JhON5CJOJQJmH sH hON5CJOJQJmH sH jJhONUjhONUjhONUj9hONUjhONUhONjhONUmHnHujhONUjhONU. N$Iflkd$$Ifs0'02aNP~$Iflkd%$$Ifs0'02a0pj$$If$ r  U"$Ifa$  9r $If gdONlkd$$Ifs0'02a02p{uo%$If#$Ifkdo$$IflF ' 0'6    4 lalDFZ\drt @B۽} hONCJhONCJOJQJmH sH jhONUjhONUjhONUj/hONUhONOJQJjhONUj?hONUjhONUhONhON5CJOJQJmH sH hON5OJQJ/oii"$IfkdF$$Ifl0'  0'624 lalpkeee"$Ifkd'$$Ifl0 '  0'622U4 lalp  BMH=71$If$If $$IfgdONgdONkd$$IflF '    0'6    22U4 lalp6^ +$$Ifa$+$If*$If 68PRfhpz|$&4(*,68@BVXZdfprjh hONUjhONUmHnHujhONUhON6OJQJjmhONUjhONUjhONUjhONUjhONU hON5hONjhONUj/hONU0^`b :hRMGC==$If dgdONkd$$Ifl Fd'd&  t 0'    2l2l2q24 l4alp hj$Iflkd $$Ifs0'02a ",.BDFPRZ\prt~ڹڮڣژڍj&hONUj^&hONUj9%hONUj$hONUj#hONUj(#hONUj"hONUhONjhONUmHnHujhONUj!hONU6$$Iflkdy"$$Ifs0'02a$&T$Iflkd$$$Ifs0'02a$Iflkd%$$Ifs0'02ad&]kdm($$Ifl''0'64lal$IfdgdONlkdJ'$$Ifs0'02adxz   !!!!8!:!N!P!^!`!b!l!n!!!!!!!tj-hONUhONOJQJj5,hONUj+hONUhON5OJQJ hON0JhON5CJOJQJmH sH hON5CJOJQJmH sH j(hONUjhONUmHnHuj'hONUjhONUhON hON6-    xr$$If$ r  U"$Ifa$  9r $If@gdON]kdi)$$Ifl''0'64lal$If {uo%$If#$Ifkd)$$IflF ' 0'6    4 lal !`!oii"$Ifkd*$$Ifl0'  0'624 lalp`!b!n!"X"keee"$Ifkd,$$Ifl0 '  0'622U4 lalp!!!!!!!""""0"2"F"H"V"X"Z"\"^"b"d"h"j"n"p""hONCJOJQJmH sH hONOJQJj/hONUhON5OJQJj.hONUj'.hONUhONjhONUX"Z"\"`"b"f"h"l"n"MKIIIIII kd}/$$IflF '    0'6    22U4 lalpn"r"t"v"""""""" & ({. A!n"p#$%tDText1vDText64vDText64jDtDText3tDText4$$Ifl!vh5d55%#v%#v#vd:V l  t 0'5&55d/ / 2l2l2q24alp vDText41vDText33vDText42vDText34vDText43vDText35vDText43vDText35tDeCheck2tDeCheck3vDText45vDText37vDText45vDText37vDText44vDText40vDText47vDText39vDText47jD{$$Ifd!vh55#v#v:V l6552 2T24vDText11vDText12$$If!vh55#v#v:V s0,55/ 24vDText13vDText17$$If!vh55#v#v:V s0,55/ 24vDText14vDText18$$If!vh55#v#v:V s0,55/ 24vDText15vDText19$$If!vh55#v#v:V s0,55/ 24vDText16vDText20$$If!vh55#v#v:V s0,55/ 24$$Ifl!vh5 55#v#v#v :V l0'6,555 /  / 4al$$Ifl!vh55 #v #v:V l 0'65 5/ / 24alptDText7tDText8$$Ifl!vh5 5#v#v :V l 0'6,55 /  / 22U4alpvDText64vDText64jDvDText102$$Ifl!vh5 5 5 #v #v #v :V l 0'6,5 5 5 /  / 22U4alptDText1vDText64vDText64jDtDText3tDText4$$Ifl!vh5d55%#v%#v#vd:V l  t 0'5&55d/ / 2l2l2q24alp vDText21vDText27$$If!vh55#v#v:V s0,55/ 24vDText22vDText28$$If!vh55#v#v:V s0,55/ 24vDText23vDText29$$If!vh55#v#v:V s0,55/ 24vDText24vDText30$$If!vh55#v#v:V s0,55/ 24vDText25vDText31$$If!vh55#v#v:V s0,55/ 24tDText5$$Ifl!vh5'#v':V l0'65'4laltDText6$$Ifl!vh5'#v':V l0'65'4lal$$Ifl!vh5 55#v#v#v :V l0'6,555 /  / 4al$$Ifl!vh55 #v #v:V l 0'65 5/ / 24alptDText7tDText8$$Ifl!vh5 5#v#v :V l 0'6,55 /  / 22U4alpvDText64vDText64jDvDText102$$Ifl!vh5 5 5 #v #v #v :V l 0'6,5 5 5 /  / 22U4alp1@@@ NormalOJQJ_HmH sH tH LL  Heading 1$@&5B*CJ<OJQJphDA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List `O` A Heading A d#CJ,OJQJ_HmHnHsH tH uJJ DHS Text 10pt1$5$7$8$9DH$NN DHS Text 12pt1$5$7$8$9DH$CJXO"XA Main SubheadOJQJ_HmHnHsH tH uBB DHS Report Hd 25CJjBjA Consumer Head d,&5CJOJQJ_HmHnHsH tH udRdA Consumer text d<OJQJ_HmHnHsH tH u<b< tableB*CJOJQJphb"b CaptiondTd7$8$H$ B*CJOJQJmH phsH udOd A Heading BdTd#CJOJQJ_HmHnHsH tH ubOb A Body textd<7$8$H$CJOJQJ_HmH sH tH >P> Body Text 2 6OJQJpp A Table headingd7$8$H$%B*CJOJQJ_HmH phsH tH F @F Footer 1$5$7$8$9DH$ 9r .)@. Page Number44 Header  !rrA small caption dx&6CJ OJQJ_HmHnHsH tH uBOB A Body small dCJRR A Body small indent!^`HO1"H A Footer left"  U"5lO2lA Footer bold left#d8&5CJOJQJ_HmHnHsH tH uHO1BHA Footer bold right$$a$>O!R>A Footer right%$a$`Ob` A side title&$a$&5CJOJQJ_HmHnHsH tH uHrH A Body 5mm tab'^`\\ DHS HD Heading($5B* CJ&KH_HmH phsH tH LL  Comment Text)1$5$7$8$9DH$CJfOfA Consumer head small *d5OJQJmHnHuhOhA Consumer text small +dCJOJQJmHnHu,O, PA Alt B*ph3f4O4  A Alt Italic6B'@B ?2Comment ReferenceCJaJXjX ?2Comment Subject/1$5$7$8$9DH$ 5CJ\HH ?2 Balloon Text0CJOJQJ^JaJ'd1PP'*dx "& "& dbcm)*+:DK! %{2^HZ   2 I J a x y   8 H I c    ! h i s  / 0 1 E   * A B Y q r @A`pq,-;MOae000*0+0Hp+0Hp+0Hp+0Hp+00000Hp0Hp00Hp00Hp0000Hp 000Hp00Hp000Hp000Hp000Hp 0 00 00Hp 0Hp 0 0Hp 0Hp 0 0Hp 0Hp 0 0Hp 0Hp 0 0Hp 0Hp 0 00 0 $0 0 #0 %0 0 "0Hp "0Hp 0 "0 "0Hp "0Hp 0 000 0 *0+0Hp+0Hp+0Hp+0Hp+0 0 00 00Hp 0Hp 0 0Hp 0Hp 0 0Hp 0Hp 0 0Hp 0Hp 0 0Hp 0Hp 0 00Hp 0 00Hp 0 00 0 $0 0 #0 %0 0 "0Hp "0Hp 0 "0 "0Hp "0Hp 0 0&0@&0@B 8 8 >!""',/49R2 L4N0^h$ `!X"n"" !#$%&()*+-.01235678:;"s nz%+3?B  #{3?EMY\     * 0 5 A G M Y _ d p v | O [ a t  y      " ( - 9 ? E Q W ] i o w$*dFFFFFFFFFFFFFFG$G$FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF856@6 5 (    C F .``TV`TV"?  C F .``TV`TV"?  C F .``TV`TV"?  C F .``TV`TV"?   C F .``TV`TV"?  C F .``TV`TV"?  C F .``TV`TV"?z  0@ "? \B  S D"?bB ! S D#" ?bB " S D#" ?bB $ S D#" ?  ( C F .``TV`TV"? bB ) S D#" ? bB . S D#" ?bB / S D#" ? bB 0 S D#" ?z 1 0@1 "?  4 C F .``TV`TV"?bB 5 S D#" ?B S  ?c:DEKz%2i dAx=t*Qtt*Qt0$t!t*Qt"[t.$t(*Qt) t/ $tmt$,tmt4m-Ttm'Nt5tmDt1Ax=t(Text1Text3Text4Text41Text33Text42Text34Text43Text35Text45Text37Text44Text40Text47Text39Text11Text12Text13Text17Text14Text18Text15Text19Text16Text20Text21Text27Text22Text28Text23Text29Text24Text30Text25Text31Text5Text6Text7Text8Text10to44N  6 N e }  . F ^ xe  !"#$%&',C $F]  1 H ` w  ) @ X p +esn,3C   ${3FM]np    1 5 H M ` d w | O b t  y     ) - @ E X ] p x w+..001134679:;bes;An,3C   $&,{3FM]Z    1 5 H M ` d w | O b t  y   F M   ) - @ E X ] p w+..001134679:;be3333333bc)*+Z   2 I J a x y   8 H I c    h i / 0 E   * A B Y q r @A`pq,-.0369e"6""z"z@ M dppp p p@ppppppp p"UnknownGTimes New Roman5Symbol3Y Arial Univers-CondensedLightObliqueTimes New RomanA Arial Narrow7 Verdana5 Tahoma 1hҫF <&r&2 D 4d^33qHP ?8Profile: Health ConditionsRobert Di RenzoRobert Di Renzo Oh+'0, DP p |  'Profile: Health ConditionsRobert Di RenzoHealth_Conditions_LO_3C.dotRobert Di Renzo3Microsoft Word 11.3.5@F#@ ?@@@/2 GHPICT@Z HHZ ZHH//,ZZ  sEVcss^kZkZskZkZsskZo{kZs Zc^Z^ZNskZ4F1NsNsRB^VR^sF1F1RNsF1JRF1cs4RsVJRF1VV9RsRR91=NsVVss-c^sco{kZsZcZ^s( RcRBF1BJR^RBBo{s( JRRJRF19=NsVJRF15cs>sRcVcg9NskZVVZRZkZg9kZkZsBscZZ^BRcsF1sF1^ZNs^VJRZ^^NsJRccssZ^g9s0s^Z^ BJRVJRZ^VVZ^o{ss$s ZRZ^ZZ^css's cVZg9VZR^^Rssss  5 kZs{{{o{ss{wso{skZw{5 ^g9VF1cBVZ5BkZcNsZ9=Ns } Zg9VcNs^Vg9^cRZg9cNscg9g9c^R^ZRVkZZg9RcR^^cRJRZkZNsR^NsVcwR^c+kZkZ^kZc^cVccRc%kZkZg9c4 c^kZcVJRkZNs^g9c^kZIccRcVkZR^RcV^ZR^ccZNskZcR^V^^cZ^kZyZ^VcV^ccZkZc^^NskZkZkZ^ZcRcR^^cRJRZkZNsRVckZg9Vcc^ZcRZcZ6 ckZRF1cZ^^ZcF1kZcckZ#g9swkZkZg9cZ==K^ccZ^kZ^ZcBcV^cg9^R^^cZZ^VcV^"ZcF1BRNsF15ccZkZc^^ckZkZkZ^kZN^ccVg9c^R^cVckZc^R^R^ckZccRkZ *kZwo{{wkZw{{o{o{{A^sNscNsNsB^sNsNsBRkZNsNsJRkZkZg9c9 Rcg9c^Nsg9^cZVcJRkZ^VNsg9{kZ3kZccNsVckZkZkZ^ZB1YZg9^^Vo{ccZRcZZg9RcR^^cRcRcVg9ckZcckZQ kZccR^kZcZcRNscV^c^Ns^cg9VVcVZRo{cRNso{NskZkZg9c]ZcZF1ZRkZV^RkZZVccZVkZc F1kZRg9JRckZZkZ^VVkZYZV^ccJRc^Z^cZcZVkZJRcZRVo{RRc^ccJRckZNswOZc^R^g9c^NsZcg9ckZVcF1V^ZR^V^^cZ^/ VVNscco{^ZccJRkZ+ kZs{{wss{kZo{+ ^g9cBkZZcF1BRNs kZkZg9c[^Rg9c^kZ^RcR^g9cRRckZc g9cVZRZcc^^R^kZ1 c^Z^Zc^VckZVJRkZ ORg9cZcRVV^^cV^VckZcVR^RcVcVRcc^Z^AZNsVkZ^JRNs^ckZg9VkZcNs^ZVkZcZRRw Mc^cZcwZg9^^JRcc^Vo{^cJRkZ^^JRkZkZccF1ccOccZkZccF1kZRg9^VkZZcZ^cZkZkZVVcZVRc^JRkZ M^ccVZRZcckZVV^kZcVkZ^c^cZVkZ^cVNsc' kZ^kZV^cVg9g9^Vcw    c^g9kZZ^Z^Z^kZNs^kZ^R^Z2g9^g9cg9^cg9F1RVZZ^kZ^g9kZNs^o{g9^Rg9g9cVcF1kZc^g9^g9g9^Ns^^c^g9^w  * ss{wckZw{{o{o{{/ZcF1BkZ9^sNsNsBRkZNsNsJR g9o{o{kZkZo{^o{o{kZo{kZkZZNso{)Vo{kZo{kZco{ZkZkZg9o{o{kZo{kZRo{o{kZg9o{g9F1^kZco{o{Z^o{Ro{o{kZkZo{o{^kZ^kZo{^Zg9^kZo{o{  kZw^w  g9wg9w  g9wZw  kZw^w  ZwkZ^w         Kg9^kZg9o{VkZZkZo{^o{g9^kZco{RkZZVg9NsZkZo{o{kZZ^c Ass^JRZNsg9R^ZRg9ZcZcsVZ^g9cZRss.sVg9Vcs^cF1c^cVsssDs^ZcsZg9ZcNsVVg9s Zcc^R^V^c^ss     ՜.+,D՜.+,Hx   '' Department of Human Services^ Profile: Health Conditions TitleP :B_PID_LINKBASE'A  !"#$%&'()*+,-./0123456789:;<>?@ABCDEFGHIJKLMNOPQRSTUWXYZ[\]^_`abcdefghijklmnopqrstuvwxz{|}~Root Entry F/Data =01TableVbDWordDocument*xSummaryInformation(y@DocumentSummaryInformation8CompObjX FMicrosoft Word DocumentNB6WWord.Document.8