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P r o f i l e : N e e d f o r A s s i s t a n c e
T o a s s i s t w o r k e r s / p r a c t i t i o n e r s t o s c r e e n f o r c o n s u m e r s n e e d f o r a s s i s t a n c e w i t h a c t i v i t i e s o f d a i l y l i v i n g . C o n s u m e r
N a m e : F O R M T E X T
D a t e o f B i r t h : d d / m m / y y y y F O R M T E X T / F O R M T E X T / F O R M T E X T
S e x : F O R M T E X T
U R N u m b e r : F O R M T E X T
o r a f f i x l a b e l h e r e Q u e s t i o n s t o a s k t h e c o n s u m e r ( o r t h e p e r s o n w h o r e p r e s e n t s t h e c o n s u m e r ) :
A r e a S c r e e n i n g Q u e s t i o n s C o m m e n t s D o m e s t i c H a s d i f f i c u l t y o r n e e d s a s s i s t a n c e a t h o m e w i t h : e . g .
D o i n g h o u s e w o r k a n d l a u n d r y
P r e p a r i n g m e a l s
S h o p p i n g f o r f o o d a n d h o u s e h o l d i t e m s
O t h e r p l e a s e s p e c i f y F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
D e t a i l s ( l i s t s p e c i f i c a r e a s o f d i f f i c u l t y )
F O R M T E X T P e r s o n a l H a s d i f f i c u l t y o r n e e d s a s s i s t a n c e w i t h : e . g .
D r e s s i n g o r g r o o m i n g
H a v i n g a b a t h o r s h o w e r
O t h e r p l e a s e s p e c i f y ( e x a m p l e t o i l e t i n g ) F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
D e t a i l s ( l i s t s p e c i f i c a r e a s o f d i f f i c u l t y )
F O R M T E X T M o b i l i t y H a s d ifficulty or needs assistance with: e.g.
Walking or moving around the house
Walking or moving around outdoors and away from home
Prompt for use of aids, wheel chairs. FORMCHECKBOX Yes FORMCHECKBOX No
Details (list specific areas of difficulty)
FORMTEXT T r a n s p o r t H a s d i f f i c u l t y o r n e e d s a s s i s t a n c e w i t h t r a n s p o r t : e . g .
U s i n g c a r s
U s i n g p u b l i c t r a n s p o r t F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
D e t a i l s ( l i s t s p e c i f i c a r e a s o f d i f f i c u l t y )
F O R M T E X T O t h e r H a s d i f f i c u l t y o r n e e d s a s s i s t a n c e w i t h a c t i v i t i e s : e . g .
M a n a g i n g m o n e y
O r g a n i s i n g a n d t a k i n g m e d i c a t i o n s
O t h e r p l e a s e s p e c i f y F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
D e t a i l s ( l i s t s p e c i f i c a r e a s o f d i f f i c u l t y )
F O R M T E X T C o g n i t i o n H a s p r o b l e m s w i t h c o g n i t i o n : e . g .
S e r i o u s p r o b l e m s w i t h m e m o r y
O b s e r v a t i o n o r e v i d e n c e f r o m G P o r c a r e r s u g g e s t s c o n f u s i o n , d i s o r i e n t a t i o n , o r p r o b l e m s w i t h m e m o r y F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
D e t a i l s ( l i s t s p e c i f i c a r e a s o f d i f f i c u l t y )
F O R M T E X T B e h a v i o u r O b s e r v a t i o n o r e v i d e n c e f r o m G P o r c a r e r s u g g e s t s p r o b l e m s w i t h b e h a v i o u r , e . g . , a g g r e s s i o n , w a n d e r i n g , a g i t a t i o n F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
D e t a i l s ( l i s t s p e c i f i c a r e a s o f d i f f i c u l t y )
F O R M T E X T C o m m u n i c a t i o n H a s d i f f i c u l t i e s w i t h s p e e c h o r h e a r i n g : e . g .
O b s e r v a t i o n o r e v i d e n c e f r o m G P o r c a r e r s u g g e s t s c o m m u n i c a t i o n d i f f i c u l t i e s F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
D e t a i l s ( l i s t s p e c i f i c a r e a s o f d i f f i c u l t y )
F O R M T E X T
R e f e r r a l R e c o m m e n d e d T o : F O R M T E X T
P r o d u c e d b y t h e V i c t o r i a n D e p a r t m e n t o f H u m a n S e r v i c e s , 2 0 0 9 T h i s i n f o r m a t i o n c o l l e c t e d b y : N F A P a g e 1 o f 1 N a m e : F O R M T E X T P o s i t i o n / A g e n c y : F O R M T E X T S i g n : D a t e : d d / m m / y y y y F O R M T E X T / F O R M T E X T / F O R M T E X T C o n t a c t n u m b e r : F O R M T E X T
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