Assessment Form - A1 Disability Support Care

A1 Disability Support Care

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info@a1disabilitysupportcare.com.au

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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 *

Gender *MaleFemalePrefer not to sayOther

Part 1

Assessment Date:

Assessment Time:

DVA Date of Admission:

Performed by

Signature:

Family /Other Present for Assessment:

Pension Number *

Receiving current care services (besides A1)YesNo

Current Service:

Provider:

ACAT AssessmentYESNO

NDISYESNO

HCP LEVEL

DVA NumberWhiteGoldOrange

Pension NumberFullPartSelf-funded

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

Contact 2 - Full Name

Relationship

Phone

Do You Have a Personal Alarm?YESNO

Type of alarm

Who pays for the alarm?

Are you on Warfarin?YESNO

Blood Test Frequency

Private Health Insurance – Basic Cover

Blood Test Frequency

Provider

Policy 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

Year

Medications

Medication

Dosage/Route

Time

Physical Assessment

VITAL SIGNS (if known)

BP

T.

Urine

P

Weight

Add further details from the above question:

GENERAL APPEARANCEThinObesePaleFlushedSweatingNormal

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

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?

Mark on the diagram the site of the pain:

Question (Non-anonymous question )File number limit: 1 Single file size limit: 10MB Allowed file types: Word, Excel, PPT, PDF, Image, Video, Audio

No file chosen

Indicate the site of the pain:HeadNeckChest - RightChest - LeftAbdomenHip - RightHip - LeftKnee - RightKnee - LeftAnkle - RightAnkle - LeftShoulder - RightShoulder - LeftBackButtocks - RightButtocks - LeftCalf - RightCalf - LeftFoot - RightFoot - LeftHand - RightHand - Left

Comments:

Treatment and/or Therapies

Bodily pain * *

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

Doctor

Treatment

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

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 Right at Home?

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?

Circumstances of Existing Carer/FamilyEmotional stress and strainEmployment issueFactors unrelated to care situationReturn to work / studyOther factorsAcute physical exhaustion / illnessSlow physical health deteriorationMaintain regular activitiesIncreasing needsOne-off event

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

What areas do you need assistance with?BathroomsDustingDishes / kitchenStripping / making bedsSocialisation and transportLawns / garden and weedingFloors (mopping / vacuuming)Meal preparationEmpty / clean binsWashing / ironingLinen change

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

If yes to any of the questions below Complete Dietary ProfileAssistance with Meal PrepAssistance with FeedingNausea / VomitingGI PainWeight Loss / GainSwallowing Difficulty

Snack

Time

Comments

If yes to any of the questions below Complete Dietary ProfileAssistance with Meal PrepAssistance with FeedingNausea / VomitingGI PainWeight Loss / GainSwallowing Difficulty

Lunch

Time

Comments

If yes to any of the questions below Complete Dietary ProfileAssistance with Meal PrepAssistance with FeedingNausea / VomitingGI PainWeight Loss / GainSwallowing Difficulty

Dinner

Time

Comments

If yes to any of the questions below Complete Dietary ProfileAssistance with Meal PrepAssistance with FeedingNausea / VomitingGI PainWeight Loss / GainSwallowing Difficulty

Alcohol Use

Time

Comments

If yes to any of the questions below Complete Dietary ProfileAssistance with Meal PrepAssistance with FeedingNausea / VomitingGI PainWeight Loss / GainSwallowing Difficulty

Personal Care

Can you shower / bath yourself?YESNO

What do you need No help with?

Can you dress your self?YESNO

What do you need help with?

What time do you usually shower or bath?

When do you usually wash your hair / shave / nails?

Do you need moisturisers / creamapplied after showering?YESNO

Where and how often?

Do you use continence aids?YESNO

Type

IDC / SPC / Stoma needs

Shower aid requirements

Do you need regular hairdresser appointmentYESNO

Hairdresser Name

Hairdresser Phone

Who makes appointment?

Do you need regular podiatrist appointmentYESNO

Podiatrist Name

Who makes appointment?

Comments

Oral and Dental Conditions

Dentist Name

Dentist Address

DentureUpperLower

PartialTopBottom

Crown

Own Teeth

State of Own Teeth

State of Gums & Oral Mucosa

Assistance needed with mouth CareYESNO

DailyAMPM

AssistancePartial AssistanceFull AssistanceSupervisionPromptingFully Independent

Comments

Skin integrity & hair

Skin:ScareRashesBruisesWoundsSkin TearsDehydratedOedemaColour

Known Skin Condition

Other Comments on skin

Hair:DryGreasyNormal

Nails:

Colour

Current Wounds

Photograph Taken:

Mobility assessment

ASSISTANCE REQUIREDIndependent with supervisionAssistance requiredFully dependentFully independent

ASSISTANCE WITH TRANSFERSbed - chairstand - sitchair - bedroll side - sidesit - standchair - chairsit up in bed/chairmoving up the bed

Number of Nurses required

Type

WEIGHT BEARINGNon weight bearingPartially Weight bearingFull weight bearing

AIDS REQUIREDWalking StickFrameWheelie WalkerArtificial LimbsWalk beltLifting Machine Type:Wheelchair DependentWheelchair Independent

Number of Staff required

EXERCISE TOLERANCEWants to exercise?No ImpairmentModerate impairmentSevere impairment

Wants to exercise?

UPPER LIMBS:

StrengthNormalMinor ImpairmentSevere Impairment

MovementNormalMinor ImpairmentSevere Impairment

SwellingYESNO

LOWER LIMBS:

StrengthNormalMinor ImpairmentSevere Impairment

MovementNormalMinor ImpairmentSevere Impairment

GaitNormalSlightly UnsteadySeverely AtaxicPhysiotherapist referral REQUIRED

Gait SwellingYESNO

Additional Comments for Care Plan

Falls Risk Assessment Score as per AS-002

Falls Risk Assessment Score as per AS-002

Extra Communication Strategies

Communication

Difficulty with comprehensionYESNO

Repetitive speechYESNO

Moderate speech impairmentYESNO

Speaks in jargonYESNO

Responds appropriatelyYESNO

Initiates conversationYESNO

Word finding difficultyYESNO

Altered tone (too loud, too soft)YESNO

Frequency Of Care Required:On all occasionsYESNO

SometimesYESNO

Degree of Assistance Required (Specify):Extra time and assistanceExtra Communication StrategiesCommunication tool

Speech therapy: Requires referral to speech therapist

Hearing assessment

Mild hearing lossYESNO

Has hearing aideYESNO

Moderate hearing lossYESNO

Needs assistance with hearing aidsYESNO

Profound Hearing lossYESNO

Refuses to wear aidesYESNO

Word finding difficultyYESNO

TinnitusYESNO

Loss in which ear?LEFTRIGHTBOTH

Frequency Of Care Required:On all occasionsYESNO

SometimesYESNO

Degree of Assistance Required (Specify):Extra time and assistanceUse gestures / communication toolNeeds assistance with cleaning and positioning hearing aid

Is there any assistance required?YesNo

Vision assessment

Legally blindYESNO

GlaucomaYESNO

Cataracts (right/left)YESNO

Dry eyesYESNO

Problems with peripheral visionYESNO

Excessive tearsYESNO

Difficulty with glareYESNO

Wears GlassesYESNO

Past surgery

Frequency Of Care Required:On all occasionsYESNO

SometimesYESNO

Degree of Assistance Required (Specify):Extra time and assistanceUnable to see small objectsUnable to see large objectsNeeds assistance with cleaning and positioning of spectacles

Sensory status

TOUCH:No ProblemDeficit (Describe):

NUMBNESS:No ProblemDeficit (Describe):

SMELL:No ProblemDeficit (Describe):

TASTE:No ProblemDeficit (Describe):

Cardiovascular status

PacemakerYesNo

Chest Pain / AnginaYesNo

Frequency

PalpitationsYesNo

AFYesNo

Treatment

Comments

Respiratory status

Chest / Breathing:CoughWheezeOxygen UseSmoking

Effect of Exertion:DyspnoeaShortness of Breath at rest

If Yes, level of use:

Treatment (e.g. Puffer):

Comments

Sleep / Rest

Any problems getting to sleep?YesNo

Comments

Any problems staying asleep?YesNo

Comments

Any problems getting back to sleep?YesNo

Comments

Do you take anything to help you sleep?YesNo

Comments

Methods to promote sleep:

What time do you:

Rise

Retire

Methods to promote sleep:

Bed rails for security?YesNo

Do you have any rest / relaxation periods?YesNo

Rest Times

Sleep assessment required?YesNo

Comments

Do you need a CPAP / BPAP Machine?YesNo

Do you need a CPAP/BPAP Machine?

Client / Participant Assessment

Do you need assistance?YesNo

Comments:

Mental State Questionnaire (MSQ)

(Tick those the client is able to correctly answer):

SCORE OUT OF 10

Or state score of MMSE if completed:

Part 3

Initial Assessment

Care Manager/Coordinator:

Signature: (Non-anonymous question )File number limit: 1 Single file size limit: 10MB Allowed file types: Word, Excel, PPT, PDF, Image, Video, Audio

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Outcome:

Graded Falls Risk:

Care Manager/Coordinator:

Signature: (Non-anonymous question )File number limit: 1 Single file size limit: 10MB Allowed file types: Word, Excel, PPT, PDF, Image, Video, Audio

No file chosen

Outcome:

Graded Falls Risk:

Care Manager/Coordinator:

Signature: (Non-anonymous question )File number limit: 1 Single file size limit: 10MB Allowed file types: Word, Excel, PPT, PDF, Image, Video, Audio

No file chosen

Outcome:

Graded Falls Risk:

Part 4

Client Details

Michael David Heery *

Heery *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

MaleMaleFemalePrefer not to sayOther

History of Falls

Number of falls in the past 12 months. Please use the scorecard below: 30 - No falls1 - 1 fall2 - 2 falls3 - 3 or more fallsOther

Describe circumstances

Was an injury sustained in any of the fall/s in the past 12 months? (rate most severe injury due to a fall in the past 12 months). Please use the scorecard below:0 - No1 - Minor injury, did not require medical attention2 - Minor injury, did require medical attention3 - Severe injury (fracture, etc.)Other

Medications

Number of prescribed medications. Please use the scorecard below:0 - No medications1 - 1-2 medications2 - 3 medications3 - 4 or more medicationsOther

Does the individual take any of the following types of medication? Sedative, antidepressant, anti-epileptics, central acting analgesic, digoxin, diuretics, anti-arrhythmic, vestibular suppressant. Please use the scorecard below:0 - None apply1 - 1-2 apply2 - 3 apply3 - 4 or more applyOther

Does the individual have a chronic medical condition/s affecting their balance and mobility? Arthritis, respiratory condition, Parkinsons disease, diabetes, dementia, peripheral neuropathy, cardiac condition, stroke, other neurological condition, lower limb amputation, osteoporosis, vestibular disorder, other dizziness, back pain, lower limb joint replacement.0 - None apply1 - 1-2 apply2 - 3 apply3 - 4 or more applyOther

Does the client have an uncorrected sensory deficit/s that limits their functional ability? If YesVisionSomatosensory

Does the client have an uncorrected sensory deficit/s that limits their functional ability? If NoVisionSomatosensory

Feet and Footwear

Does the client have foot problems? e.g. corns, bunions, swelling etc.0 - No1 - Yes

Does the client have inappropriate, poorly fitting or worn footwear?0 - No1 - Yes

Cognitive Status

AMTS ScoreAgeTime to the nearest hourAddress to recall (42 West St)Current yearCurrent locationRecognition of two personsDate of birthYear of first World WarName of current Prime MinisterCount backwards from 20 by ones Score: /10

Correct no. reponses:0 - 9-10 correct1 - 7-8 correct2 - 5-6 correct3 - 4 or less correct

Continence

Is the individual continent?0 - Yes1 - No

Does the individual regularly have to go to the toilet in the night 3 or more times? (if uses a bottle, rate as 0)0 - Yes1 - No

Nutritional Status

Has the individuals food intake declined in the past three months due to a loss of appetite, digestive problems, chewing or swallowing difficulties?0 - No1 - Small change2 - Moderate loss of appetite3 - Severe loss / poor intake

Weight loss during the last 3-12 months.0 - Nil1 - Minimal, less than 1 kg or unsure2 - Moderate 1-3 kg3 - Marked, greater than 3 kg

Number of alcoholic drinks consumed in the past week.0 - Nil1 - 1-32 - 4-103 - 11 or more

Did the home environment appear safe?

Did the home environment appear safe?0 - Yes1 - Minimal environmental hazards2 - Moderate environmental hazards requiring modification3 - Extremely unsafe environment

Functional Behaviour

Observed behaviours in Activities of Daily Living and Mobility include:0 - Consistently aware of current abilities / seeks appropriate assistance as required1 - Generally aware of current abilities / occasional risk-taking behaviour2 - Under-estimates abilities / inappropriately fearful of activity3 - Over-estimates abilities / frequent risk-taking behaviour

Function

Prior to this fall, how much assistance was the individual requiring for personal care activities of daily living? (NOTE: If no fall in the last 12 months, rate current function)0 - None / independent1 - Supervision2 - Some assistance required3 - Completely dependent

Has this changed since the most recent fall? (leave blank if no falls in 12 months)0 - No1 - Yes

Prior to this fall, how much assistance was the individual requiring for instrumental activities of daily living? (NOTE: If no fall in the last 12 months, rate current function)0 - None / independent1 - Supervision2 - Some assistance required3 - Completely dependent

Has this changed since the most recent fall? (leave blank if no falls in 12 months)0 - No1 - Yes

Balance

Does the individual, upon observation of walking and turning, appear unsteady or at risk of losing their balance? (NOTE: Rate with usual walking aid. Select one only, if level fluctuates, tick the most unsteady rating)0 - No unsteadiness observed1 - Yes, minimally unsteady on walking or turning2 - - Yes, moderately unsteady on walking or turning (needs supervision)3 - Unsafe

Gait / Physical Activity

Can the individual walk safely around their home? If aid is used:0 - Independent, no aid needed1 - Independent with an aid2 - Safe with supervision / assistance3 - Unsafe

Can the individual walk safely in the community? If aid is used:0 - Independent, no aid needed1 - Independent with an aid2 - Safe with supervision / assistance3 - Unsafe

How physically active is the individual?0 - Very active (exercises 3 times per week)1 - Moderately active (exercises less than twice per week)2 - Not very active (rarely leaves the house)3 - Inactive (rarely leaves one room of the house)

Has this changed since the most recent fall?0 - No1 - Yes

Grading of Falls Risk:

Implement actions for identified individual risk factors, and recommend health promotion behaviour to minimise future ongoing risk (e.g. increased physical activity, good nutrition).Mild falls riskModerate falls riskHigh falls risk

Implement actions for identified individual risk factors.Mild falls riskModerate falls riskHigh falls risk

Implement actions for identified individual risk factors, and implement additional actions for high falls risk (e.g. refer to a specialist Falls Clinic or physiotherapist).Mild falls riskModerate falls riskHigh falls risk

Initial Assessment

Care Manager / Coordinator:

Outcome:

Graded Falls Risk:

Name of the Care Manager / Coordinator:

Outcome of the assessment:

Graded Falls Risk:

Signature: (Non-anonymous question )File number limit: 1 Single file size limit: 10MB Allowed file types: Word, Excel, PPT, PDF, Image, Video, Audio

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Date Reviewed:

Care Manager / Coordinator:

Outcome:

Graded Falls Risk:

Signature: (Non-anonymous question )File number limit: 1 Single file size limit: 10MB Allowed file types: Word, Excel, PPT, PDF, Image, Video, Audio

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Form No: AS-001

Client Assessment

Assessment Time

Performed by

Family / Other Present for Assessment

Receiving current care services (besides RAH)YESNO

Current Service

Provider

Current Service

Provider

HTML

Behaviour / Emotional Needs

Behaviour / Emotional Needs

Are there any known precipitating factors to the above?

Any sign of depression?

Hints for successful management strategies

Are any challenging behaviours likely to put staff at risk? (if yes, refer to Policy WS020)YESNO

Frequency of interventions requiredConstantlyFrequentlyWeeklyOccasionallyDaily

Continence

Are you incontinent?YesNo

Do you rush to toilet / dont make it?YesNo

Do you have a catheter / colostomy etc?YesNo

Type

Do you wear continence aids?YesNo

Do you have a prostate problem?YesNo

Do you suffer from constipation?YesNo

Palliative Care

Is the client palliative?YesNo

Is medication management required?YesNo

Medication Management / Assistance

Medication allergies list

Abilities / DeficitsPoor visionYesNo

Resistive to medicationsYesNo

Difficulties swallowing tabletsYesNo

Potential to hide or spit out medicationsYesNo

Poor hand function / coordinationYesNo

Cognitively impairedYesNo

Degree of assistance requiredSome assistanceYesNo

Crush tabletsYesNo

Puffers / creams / eye-drops / nebuliserYesNo

Put tablets on spoonYesNo

Observe ingestionYesNo

Controlled drugsYesNo

Medication DispenserWebster packYesNo

Pill boxYesNo

Individual packagingYesNo

OtherYesNo

COMMENTS

RISK ASSESSMENT

Nature of risk

Likelihood of occurrenceRarePossibleFrequentOccasional

ConsequenceMinorSevereCatastrophic

Preventative measures required

Frequency of care required:

HTML

Client Request for Service
Services requested by the client / family - Details to be included in the Care Plan e.g. time and day

Daytime care - activities of daily living

Night time care - activities of daily living

Daytime respite - in-home

Overnight respite - in-home

Meal preparation

Domestic support - cleaning, shopping etc

Social contact - visit friends, movies, theatre, library, shopping

Fitness - exercise - swimming etc.

Transport by carer in carers care

Transport using clients own vehicle Client to sign CL-008 Client Vehicle Declaration

Home modification

Home maintenance

Provision of goods and equipment (specialised)

Medication management

Nursing (skilled) care

Allied Health Care - rehab.

Liaison / advice / support / counselling

Signature: (Non-anonymous question )File number limit: 1 Single file size limit: 10MB Allowed file types: Word, Excel, PPT, PDF, Image, Video, Audio

No file chosen

At A1 Disability Support Care we are dedicated to enhancing the lives of individuals with disabilities across Queensland.

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Shop 5 / 218 Padstow Road, Eight Mile Plains, QLD - 4113
info@a1disabilitysupportcare.com.au