• Participant Assessment and History

    Participant Assessment and History

  • Assessment date
     / /
    2 digit day, 2 digit month, 4 digit year :

  • Participant Details

  • Date of Birth:
     / /
    2 digit day, 2 digit month, 4 digit year
  •  -
  • Country of Birth:
  • Does the Participant identify as an Aboriginal or Torres Strait Islander?
  • Does the Participant have a Primary Representative?
    •  
    •  -
    • What is the scope of the planned service as per this meeting?
    • Participants 
    • Who participated in the development of this assessment?
    • Has this Participant legally appointed decision makers?
    • Power of Attorney:
    •  -
    • Enduring Power of Attorney:
    •  -
    • Guardian:
    •  -
    • Financial Manager:
    •  -
    • Additional Participant Information 
    • Any contact precaution required?
    • Does the Participant suffer from Epilepsy?
    • Date Epilepsy was diagnosed:
       - -
      2 digit day, 2 digit month, 4 digit year
    • Date of last seizure:
       - -
      2 digit day, 2 digit month, 4 digit year
    • Are the seizures managed by regular medication?
    • Does the Participant have a current management plan?

    • Please obtain a signed management plan from a health professional.

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    • Does the Participant suffer from Asthma?
    • Date Asthma was diagnosed:
       - -
      2 digit day, 2 digit month, 4 digit year
    • Date of last Asthma attack:
       - -
      2 digit day, 2 digit month, 4 digit year
    • Is the Asthma managed by regular medication?
    • Does the Participant have a current management plan?

    • Please obtain a signed management plan from a health professional.

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    • Instrumental Activities of Daily Living (AIDL) 
    • Phone Use
    • Preparation of Food
    • Housekeeping
    • Laundry
    • Home Environment maintenance
    • Transport
    • Shopping
    • Finances
    • Managing Medications
    • Sensory and Communication 

    • Speech

    • Is the Participant from a culturally and linguistically diverse background?
    • Does the Participant require an interpreter?
    • Can the Participant initiate conversations?
    • Does the Participant require a strong volume of voice to communicate?
    • Is the Participant able to find the right words to communicate
    • Any specific communication problems?
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    • Vision

    • Does the Participant use glasses?
    • Is it cleaned by the staff?
    • Is it being worn by the Participant as prescribed?
    • Are the glasses placed on/off by staff?

    • Smell and Taste

    • Does the Participant have any smelling impairment?
    • Does the Participant have any tasting impairment?

    • Hearing

    • Does the Participant use hearing aid/s?
    • Is it put in by the staff?
    • Is it being worn by the Participant?
    • Who changes the hearing aid battery?
    • Who cleans the hearing aid battery?
    • Does the Participant need additional assessment or follow up by a health professional?
    • Additional Information:
    • Mobility and Transfers 
    • Is there an assessment from a licensed Physiotherapist?
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    • Has the Participant had any recent fall/s?

    • Please complete the Falls Risk Assessment.

    • Identified falls risk:
    • Transfers:
    • Ambulation and Aids:

    • Balance (Sitting):
    • Balance (Standing):
    • Does the Participant need additional assessment or follow up by a health professional?
    • Additional Information:
    • Skin Integrity 
    • Has the Participant had any history of the following?

    • Please complete the Norton Skin Risk Assessment tool

    • Any wound present?

    •  Note: Only Care does not provide any wound care services.

    • Are there any pressure ulcers?

    • Please complete the Pressure Ulcer Risk Assessment tool.

    • Date Occurred:
       - -
      2 digit day, 2 digit month, 4 digit year
    • Does the wound require dressings?
    • Current management strategies to anti-pressure interventions:
    • Does the Participant need additional assessment or follow up by a health professional?
    • Additional Information:
    • Toileting 
    • Does the the Participant require assistance?
    • Level of assistance:
    • Additional Information:
    • Bladder 
    • Is the Participant continent?
    • When does this occur?

    • Does the Participant need additional assessment or follow up by a health professional?
    • Is the Participant using any aids?

    • Is the Participant using any pads?

    • Additional Information:
    • Bowels 
    • Is the Participant continent?
    • When does this occur?

    • Does the Participant need additional assessment or follow up by a health professional?
    • How is it managed?
    • Preferred toileting time/s:
    • Additional Information:
    • Diet (Eating and Drinking) 
    • Does the Participant have any food allergies?
    • Does the Participant have any problems swallowing?
    • Does the Participant need additional assessment or follow up by a health professional?
    • Does the Participant require assistance?
    • Dietary Needs:

    • Feeding route:

    • Texture of food preferred by the Participant:
    • Any Aids:

    • Drinks:
    • Additional Information
    • Hygiene Needs 
    • Is any Personal Protective Equipment (PPE) and/or Sanitisation or Waste Disposal (e.g. Sharps or Clinical Waste Disposal Systems) supplies required, recommended or requested for some or all parts of service with the Participant?
    • Is Provider/Staff (for suggested service) required to supply their own PPE?
    • Bathing:
    • Preferred bath routine:
    •  :
    • Preferred bath/shower products:

    • Staff required assistance:
    • Dressing/ Grooming:
    • Staff required assistance:

    • Does the Participant need assistance with cleaning/cutting fingernails?

    • Please refer to a podiatrist or similar service. We do not provide this service.

    • Does the Participant need assistance to the hair dresser?
    • Does the Participant need additional assessment or follow up by a health professional?
    • Additional Information:
    • Sleep Management 
    • Does the Participant need daytime rest?
    • Identified sleeping problems:

    • Assistive device used :

    •  :
      Until
       :
    •  :
      Until
       :
    • Is the Participant wandering?
    • Does the Participant need additional assessment or follow up by a health professional?
    • Additional Information:
    • Medications 
    • Does the Participant take medications?
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    • If required, photograph of documentation
    • Does the Participant have any known drug allergies?
    • Medication Management:
    • Other activities that may impact medication:

    • Does the Participant need additional assessment or follow up by a health professional?
    • Additional Information:
    • Pain Management 
    • Is the Participant stating that they are experiencing pain?
    •    
    • Pain management strategies:

    • Does the Participant need additional assessment or follow up by a health professional?
    • Additional Information:
    • Cognitive Status 
    • Participant's Memory:
    • Participant's Orientation:
    • Participant's Communication:

    • Questions adapted from SHORT PORTABLE MENTAL HEALTH STATUS QUOTIENT to be asked by the assessor:

    • 1. What is the date today?
       / /
      2 digit day, 2 digit month, 4 digit year
    • Is the answer correct?
    • Was the Participant prompted?
    • Is the answer correct?
    • Was the Participant prompted?
    • Is the answer correct?
    • Was the Participant prompted?
    • Is the answer correct?
    • Was the Participant prompted?
    • 5. When were you born?
       / /
      2 digit day, 2 digit month, 4 digit year
    • Is the answer correct?
    • Was the Participant prompted?

    • Complete RUDAS or The Psychogeriatic Scale if scored 2 or less.

    • Does the Participant need additional assessment or follow up by a health professional?
    • Additional Information:
    • Behaviour Management 
    • Does the Participant have any behaviors of concern ?
    • Is there a current Behaviour Support Plan?
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    • Please obtain a support plan from a specialist/health professional.

    • Does the Participant need additional assessment or follow up by a health professional?
    •  
    • Is there any other report or relevant information included in this assessment?
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    • Assessor comments on the information collection process (more than one option can be chosen)
    • Should be Empty: