Resident Assessment (Form-0009)

RESIDENT'S ASSESSMENT (Form-0009)
Resident's Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Gender
Address
PLEASE INDICATE Y / N in the column which describes the Resident's needs in each area.
1.0 Daily Living Activities

Personal Hygiene

Rows	No Assistance Required	Continuous Need	Details / Comments
bathing / showering
grooming
personal hygiene (teeth cleaning, shaving)

Continence

Eating

Rows	No Assistance Required	Continuous Need	Details / Comments
eating
eating aids

Dressing

Rows	No Assistance Required	Continuous Need	Details / Comments
dressing
undressing
dressing aids
ambulation (walking)
transfers (moving between sitting / standing / lying)
negotiating stairs
mobility aids (wheel chair / frame / cane)
use of safety devices (e.g handrails)
use of transport

Communication

Rows	No Assistance Required	Continuous Need	Details / Comments
assistance to address difficulties

Cognition & Perception

Rows	No Assistance Required	Continuous Need	Details / Comments
Orientation
Memory
Wandering
Personal safety (use of household appliances / emergency response / stranger treatment)

Health Issues

Rows	No Assistance Required	Continuous Need	Details / Comments
Taking medication
Other regular health needs (diabetics, wound dressings, nebuliser, epilepsy)
Personal injury (ability to attend to minor first aid and/or seek assistance)
Medical (ability to recognise need for medical intervention and initiate assistance)

Administration of Medication
Practitioner's Signature
I certify that this Resident requires continuous assistance with above assessed care services.
Resident's Name
Practitioner
Provider No.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Note: to meet the requirements for services to be GST free, a Resident must be assessed as needing, on a continuous basis, either physical assistance or supervision / prompting with one of the services listed under Daily Living Activities.
Should be Empty:

RESIDENT'S ASSESSMENT (Form-0009)