Assessment Form - A1 Disability Support Care

A1 Disability Support Care

Brisbane: 07 3473 1700
Melbourne: 03 9970 1700
info@a1disabilitysupportcare.com.au

Mon - Friday 9am -5pm

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Client Details

Client First Name

Client Last Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email

DOB

GenderMaleFemalePrefer not to sayOther

Part 1

Care Manager/Coordinator:

Assessment Date:

Assessment Time:

DVA Date of Admission:

Performed by

Signature:

Family /Other Present for Assessment:

Receiving current care services (besides A1)YesNo

Current Service:

Provider:

ACAT AssessmentYesNo

NDISYesNo

HCP LEVEL

DVA NumberWhiteGoldOrange

Pension Number

Expiry of Pension Number

Pension TypeAgesDisability

Medicare Number

Expires:

Marital Status

Phone (m)

Phone (h)

Other person able to speak on client’s behalf

Phone (m)

Phone (h)

Email

Next of Kin

Name

Phone (h)

Relationship

Phone (m)

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email:

Living Arrangements

Residential Circumstances:AloneWith SpouseWith Family MemberOther

Does client own the house/unitYesNo

Part of a retirement or assisted living communityYesNo

In Case of Emergency

Actions to be taken (ring 000, NFR etc)

Emergency Contacts

Contact 1 - Full Name

Relationship

Phone

Contact 2 - Full Name

Relationship

Phone

Contact 3 - Full Name

Relationship

Phone

Do You Have a Personal Alarm?YesNo

Type of alarm

Who pays for the alarm?

When is it due date?

Are you on Warfarin?YesNo

Blood Test Frequency

Blood Test Frequency

Provider

Reference Number

Private Health Insurance – Hospital Cover

Provider

Policy Number

Motor vehicle insurance

Provider

Policy Number

Household insurance

Provider

Policy Number

Other Insurance

Provider

Policy Number

Financial and Legal Profile

Power of attorneyYesNo

Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email

Phone

Mobile

GuardianshipYesNo

Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Mobile

Do you have a DNR in place?YesNo

Where is the DNR kept?

Advance Health Directive

Staff need to obtain a copy for the officeYesNo

Would you like to be resuscitatedYesNo

Persons responsible for fees if in addition to the client

Name 1

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email 1

Name 2

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email 2

Is the client capable of making their own decision?YesNo

Are there concerns about the stability of living arrangements (financial)?YesNo

Are there any legal issues around the living conditions (ie AVO)?YesNo

Cultural and Spiritual Values / Beliefs

Actively practicing religious beliefs?

Requires assistance to contact Minister, Pastor, Priest, Rabbi etc?YesNo

Cultural/Spiritual requests?

Client Background

Country of Birth

Main language spoken at home

Can communicate well in English?YesNo

Interpreter requiredYesNo

Has the client expressed the need for a carer that can speak the home language?YesNo

History

Medical Contacts

General Practitioner

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Pharmacy

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Treating Specialist

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Preferred Hospital

Other Contacts

Client Medical & Surgical History

Details

Medications

Medication

Dosage/Route

Time

Medication

Dosage/Route

Time

Medication

Dosage/Route

Time

Medication

Dosage/Route

Time

Medication

Dosage/Route

Time

Medication

Dosage/Route

Time

Medication

Dosage/Route

Time

Medication

Dosage/Route

Time

Medication

Dosage/Route

Time

Medication

Dosage/Route

Time

Physical Assessment

VITAL SIGNS (if known)

BP

T.

Urine

P

Weight

Add further details from the above question:

General Appearance

Circumstances of Existing Carer/Family

AllergiesYesNo

Medication Type

Reaction

Other (e.g. tape)

Reaction

Do you use an EpiPen etc for allergic reactions?YesNo

What allergy is it used for?

Where is it located?

Immunisation History

Last Influenza Vaccination

Last Hepatitis B Vaccination Date

Last Tetanus Vaccination Date

Last Pnemuovax Date

PAIN (includes soreness, stiffness, aches and pains)Chronic PainAcute Pain

How Long have you had the pain / onset / duration?

How would you describe the pain?

How bad is the pain (0=no pain 10= worst pain)

Is a pain chart required?YesNo

What causes or makes the pain worse?

What helps the pain?

Indicate the site of the pain:

Comments:

Treatment and/or Therapies

Bodily pain *

If bodily pain, has the client seen a health professional about the problem? If not, is a referral needed?YesNo

Doctor

Treatment

Contacting A1 Disability Support Care

Why have you contacted A1 Disability Support Care?

What do you hope will change if you receive our services?

What was the trigger for contacting us?

Hospital dischargeYesNo

Fall(s)YesNo

Acute medical conditionYesNo

Respite for existing carerYesNo

Concern about increasing frailtyYesNo

Loneliness / isolationYesNo

ImmobilityYesNo

Any other reason?

How did you find A1 Disability Support Care??

If not a self-referral has client given consent for referral to us?YesNo

If NO would consent be forthcoming?

Is the Client / family caring for another person?

Describe details for the Care Plan

Is there any evidence of previous difficulties between the person and health and community service providers?

Relationship with other service providers

Part 2

Domestic Assistance Assessment

Select

Nutrition / Hydration

Shopping / Errands

Checking Mail

Other (eg. Garbage bins etc)

Days and time required

Socialisation and Transportation

Lawns / Gardening (Frequency and time usually taken)

Meal

Breakfast

Time

Comments