Please complete on first session, unless referred from ACAT /DTU /RITH and have access to assessment form Client informed consent for assessment and sharing of information:  Yes  No Assessment Date: Assessor: Referral source: NOK/Main Contact: Tel: Relationship: Usual GP: GP Tel: Fax: Reason for Referral: Initial Date Current history /precautions: Past medical history: Social & Domestic Assessment Initial Date Employment status:□ □ Employed □ Unemployed □ Retired for age - Pension / Self-funded □ Retired for disability Please state previous employment: Marital status:□ □ Married Driving Status: Living arrangements:□ □ Spouse/partner □ Relative/friend □ Alone Carer: □ Yes □ No Carers Name: Relationship: . Age >70yr: □ Yes □ No Carer living-in: □ Yes □ No Uses respite: □ Yes □ No Employed: □ Yes □ No Carers health: . Frequency of contact with client (inc phone) □ Daily □ 1x per wk □ 2-3x per wk □ Variable Type of help provided by carer: . Carers perception of major issues: Advanced Health Directive /EPA /EPG: □ Yes, please provide details: □ No Personal Alarm: □ Yes □ No DVA: □ Yes – circle type: White /Gold □ No DVA Previous ACAT assessment: □ Yes - assessment date: / /_____ □ No ACAT □ TCP Approval type □ Residential □ High Care □ Low Care □ Residential Respite □ High Care □ Low Care □ Home Care Packages □ Level 1 + 2 □ Level 3 + 4 Service provider: Service type/care provided: Comments If any concern, please refer to Social Worker Referral completed:  Yes  No
Current Observations / System Review Initial Date Pain□ □ No □ Yes Details: Dizziness□ □ No □ Yes Details: Short breath on exertion/rest□ □ No □ Yes Details: Visual impairment□ □ No □ Yes – refer to OT Details : Glasses□ □ No □ Yes Eyes tested in last 2yrs□□□ No □ Yes Hearing impairment□ □ No □ Yes – hearing aids? □ No □ Yes Details: Smoking□ □ Never □ Quit date: / /____ Consumption: Alcohol□ □ Never □ Quit date: / / Consumption: type: Sleep/rest pattern Problem falling asleep □ Yes □ No Problem staying asleep □ Yes □ No Sleeping tablets taken? □ Yes □ No If ‘yes’ please specify below: Type: How often: Comments Medication Initial Date Administration□ □ Self □ Supervised □ Assistance, please specify: Concern expressed about compliance □ No □ Yes Aids/support used□ □ Webster/blister pack □ Dosette Box □ Boxes/bottles □ Timer 5 or more medications□ □ No □ Yes Difficulties swallowing medication□ □ No □ Yes If any concern, action taken: Advised visit GP OT referral  SW referral  discuss in team meeting  Communication & Swallowing Initial Date Do you have any difficulties swallowing food, fluids or medications? e.g. coughing, choking. □ Yes □ No Have you noticed any changes to your speech/voice? e.g. less clear, more effortful, difficulty thinking of or saying words. □ Yes □ No Are you having difficulty understanding language or writing? e.g. difficulty making sense of a sentence, conversation or written information. □ Yes □ No If any concern please refer to Speech Pathologist Referral completed?  Yes  No Mobility Initial Date Transfers □ □ Independent □ Requires assistance Aids: Indoor ambulation□ □ Independent □ Requires assistance Aids: Outdoor ambulation□ □ Independent □ Requires assistance Aids: Stairs□ □ Independent □ Requires assistance Aids: If any concern please refer to Physio Referral completed?  Yes  No