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{\footer\pard\qc\plain\f0\fs18 Southern Division of General Practice, Aug 2007                                                  Health Assessment Questionnaire - Page {\txfielddef{\*\txfieldstart\txfieldtype3\txfieldflags16}{\*\txfielddatadef\txfielddatatype3\txfielddata 00030001}{\*\txfieldtext \plain\f0\fs18 7}{\field{\*\fldinst {\plain\f0\fs18 PAGE }}{\fldrslt{\plain\f0\fs18 1}}}}\par}\pard\s16\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs32\b\i Health Assessment Questionnaire\par\plain\f1\fs12\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx10772\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\b Patient Name:\plain\f1\fs24   {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Patient Demographics:Full Name>>{\*\txfieldend}\plain\f1\fs24               \plain\f1\fs24\b Date: \plain\f1\fs24  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Miscellaneous:Date>>{\*\txfieldend}\plain\f1\fs24\par\pard\s16\intbl\sb113\sa113\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371 Do you identify as Aboriginal or Torres Strait Islander?       Yes\plain\f1\fs20   \plain\f2\fs36 o\plain\f1\fs20\tab            No \plain\f0\fs20  \plain\f2\fs36 o\plain\f1\fs24\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs28\b\i Living Arrangements\plain\f1\fs24\par\plain\f1\fs20\b 1\tab Are you living: \plain\f1\fs20\tab Alone  \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab As a couple \plain\f0\fs20  \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab With others \plain\f0\fs20  \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs24\par\par\plain\f1\fs28\b\i Current Health\plain\f1\fs24\b\par\pard\intbl\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20\b 2\tab In general, would you say your health is:\plain\f1\fs20\par\pard\intbl\tx900\tx2520\tx2970\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tab Excellent  \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 Very Good  \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab Good  \plain\f2\fs36\loch\f2\hich\f2 \'a8 \plain\f1\fs20\tab Fair   \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab Poor \tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\tx900\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b 3\tab Current health problems:\par\par _____________________________________________________________________________________________________\par\pard\intbl\plain\f1\fs24\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b _____________________________________________________________________________________________________\par\par _____________________________________________________________________________________________________\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs20\b\par\pard\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b 4\tab Community services currently provided:\plain\f1\fs20\par\pard\intbl\tx540\tx2250\tx2700\tx3600\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tab Daycare\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab Respite care\tab\loch\f1\hich\f1 \'a8\plain\f2\fs36  \plain\f1\fs20 HACC \loch\f1\hich\f1 \'96 Home Help\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab Community Nursing\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\tx540\tx2250\tx2700\tx3600\tx4680\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tab Meals on Wheels\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab Podiatry\tab                   \loch\f1\hich\f1 \'a8\plain\f2\fs36  \plain\f1\fs20 Physiotherapy\tab                \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs20           Transport (ie Access Cabs, community transport) \loch\f1\hich\f1 \'a8\plain\f2\fs36  \plain\f1\fs20 Other (\plain\f1\fs20\i please specify) \plain\f1\fs20\b ________________________________\plain\f1\fs24\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par\pard\plain\f1\fs20\b 5        Vaccinations:\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Clinical Details:Immunisation List>>{\*\txfieldend}\plain\f1\fs24\par\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\par\plain\f0\fs20 Comments:\plain\f0\fs24  ____________________________________________________________________\par\par\plain\f1\fs20\b 6     Medications:\plain\f1\fs24\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Clinical Details:Medication List>>{\*\txfieldend}\plain\f1\fs24\par\pard\fi-540\li540\tx540\tx2250\tx2700\tx3544\tx4680\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\plain\f1\fs20 Manages own medicine\tab Yes  \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab No  \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\fi-540\li540\tx540\tx1980\tx2268\tx2835\tx3544\tx4680\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20 Compliance difficult\tab\tab Yes  \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 No  \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs20 Comments: \plain\f1\fs24 ______________________________________________________________________________\par\par\plain\f1\fs20\b 7     Smoking:\plain\f1\fs24\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Clinical Details:Smoking>>{\*\txfieldend}\plain\f1\fs24\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Clinical Details:Smoking Quitting Stage>>{\*\txfieldend}\plain\f1\fs24\par\par\plain\f1\fs20 Comments:\plain\f1\fs24  ______________________________________________________________________________\par\plain\f1\fs24\b\par\plain\f1\fs20\b 8     Alcohol:\plain\f1\fs24\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Clinical Details:Alcohol>>{\*\txfieldend}\plain\f1\fs24\par\par\plain\f1\fs20 Comments: \plain\f1\fs24 ______________________________________________________________________________\par\page\plain\f1\fs12\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrr\brdrs\brdrw10\cellx5386\clvertalt\clbrdrl\brdrs\brdrw10\cellx10772\pard\widctlpar\intbl\pard\intbl\fi-540\li540\tx540\tx900\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20\b 9A\tab Social Function / Support\par\plain\f1\fs20\tab During the last 4 weeks, was someone available to help if you needed or wanted help?  For example,\par{\pntext\pard\intbl\plain\f3\fs20\'b7\tab}\pard\intbl\fi-360\li1080\tx540\tx1080\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls1\ilvl0{\*\pn\pnlvlblt\ilvl0\ls1\pnstart1\pnf3\pnfs20\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}felt very nervous, lonely or sad\par{\pntext\pard\intbl\plain\f3\fs20\'b7\tab}\ls1\ilvl0{\*\pn\pnlvlblt\ilvl0\ls1\pnstart1\pnf3\pnfs20\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}became sick and had to stay in bed\par{\pntext\pard\intbl\plain\f3\fs20\'b7\tab}\ls1\ilvl0{\*\pn\pnlvlblt\ilvl0\ls1\pnstart1\pnf3\pnfs20\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}needed someone to talk to\par{\pntext\pard\intbl\plain\f3\fs20\'b7\tab}\ls1\ilvl0{\*\pn\pnlvlblt\ilvl0\ls1\pnstart1\pnf3\pnfs20\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}needed help with daily chores\par{\pntext\pard\intbl\plain\f3\fs20\'b7\tab}\ls1\ilvl0{\*\pn\pnlvlblt\ilvl0\ls1\pnstart1\pnf3\pnfs20\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}needed help just taking care of yourself\par\pard\intbl\li540\tx540\tx3330\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520 Yes, as much as I wanted\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par Yes, quite a bit\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par Yes, some\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par Yes, a little\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-540\li540\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360              No, not at all\tab                           \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\par\pard\intbl\fi27\li540\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360 Do you regularly participate in a religious or other social activity?\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\plain\f1\fs20 Do you meet with any friends or family at least once a fortnight \tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-540\li540\tx540\tx1800\tx2160\tx2880\tx3330\tx4680\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b 9B\tab Do you have any paid help?\par\pard\intbl\fi-540\li540\tx540\tx900\tx1134\tx1843\tx2410\tx3119\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs20\tab Yes\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 Don\loch\f1\hich\f1 \'92t know\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-540\li540\tx540\tx900\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tab If so, is it satisfactory?\par\pard\intbl\fi-540\li540\tx540\tx1134\tx1843\tx2410\tx3330\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-540\li540\tx540\tx1800\tx2160\tx2880\tx3330\tx4680\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab Do you care for another person who needs help?\par\pard\intbl\fi-540\li540\tx540\tx567\tx1134\tx1800\tx2410\tx2880\tx3330\tx4680\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-540\li540\tx540\tx1800\tx2160\tx2880\tx3330\tx4680\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab If yes, how many hours per day? ____________\par\tab How does this affect your health and well being?\par\pard\intbl\sl360\slmult1\tx540\tx1800\tx2160\tx2880\tx3330\tx4680\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab _________________________________________\par\pard\s3\intbl\fi-540\li540\tx540\tx900\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20\b 10\tab Feelings\par\pard\intbl\fi-540\li540\tx540\tx900\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20\tab During the last 4 weeks, have you been feeling emotional such as anxious, depressed, irritable or downhearted?\par\pard\intbl\fi-540\li540\tx540\tx900\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tab\tab Not at all      \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab Slightly\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\par\tab\tab Moderately  \plain\f2\fs36\loch\f2\hich\f2 \'a8  \plain\f1\fs20\tab Quite a bit\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\par\tab\tab Extremely      \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\par\pard\intbl\fi-540\li540\tx540\tx900\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20\b 11\tab Nutrition\par\pard\intbl\fi-900\li900\tx540\tx900\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20\tab a.\tab Do you have an illness or condition that has changed the type and/or amount of food you eat?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 2\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 1\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab b.\tab How many meals do you eat per day?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab  \tab One \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab  2    Two \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36  \plain\f1\fs20 1 Three \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20  0\tab\par\tab c.\tab Do you eat at least 2 serves of fresh fruit and vegetables on most days?\par\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 0\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 2\par\tab d.\tab Do you eat at least 2 serves of dairy products \line on most days?\par\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 0\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 2\par{\listtext\pard\intbl\plain\f1\fs20 e.\tab}\pard\intbl\fi-360\li900\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\ls2\ilvl0 Do you have 3 or more glasses of beer, wine or \par\pard\intbl\li851\tx540\tx851\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200 spirits almost every day?\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs20\tab          Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 3\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 0\tab\plain\f1\fs24\cell\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20           f.\tab Do you have 6 \loch\f1\hich\f1 \'96 8 cups of fluids most days?\par\tab\tab Yes        \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 0\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 1\par           g.\tab Do you have teeth, mouth or swallowing problems that make it hard to eat?\par\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 4\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 0\par\tab h.\tab Do you always have enough money to buy food?\par\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 0\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 3\par\tab i.\tab Do you eat alone most of the time?\par\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 2\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 0\par\tab j.\tab Do you take 3 or more prescribed or over the counter medicines every day?\par\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 3\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 0\par\pard\intbl\fi-851\li851\tx567\tx851\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab k.\tab Are you always able to shop, cook and/or feed yourself?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 0\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab 2\par\par\tab TOTAL score   \par\plain\f1\fs8\par\plain\f1\fs20\tab 0 \loch\f1\hich\f1 \'96 3 Good, 4 \'96 5 Moderate risk, 6 \'96 29 High risk\par\pard\intbl\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 12       Home Safety & Risk Assessment for falls / injuries\par\pard\intbl\qj\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs16\i Note: A comprehensive assessment by an allied health professional may be of benefit for this patient.  If so, please provide details of person to whom the patient is to be referred below. You may then go directly to Question 14.\par\plain\f1\fs10\i\par\pard\intbl\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20 Name / Organisation_______________________________\par\plain\f1\fs10\par\plain\f1\fs20 Address _________________________________________\par\plain\f1\fs10\par\plain\f1\fs20 ________________________________________________\par\plain\f1\fs10\par\plain\f1\fs20 Telephone: __________________ Fax: ________________\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs10\par\plain\f1\fs20\i If not, please complete the following:\par\plain\f1\fs10\par\plain\f1\fs20\tab a.\tab Can you get up from your lounge chair easily?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab b.\tab Can you get in and out of bed easily and safely?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab c.\tab Can you switch a light on easily from your bed?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab d.\tab Can you get on and off the toilet easily\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab e.\tab Do you have floor mats that slip?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par{\listtext\pard\intbl\plain\f1\fs20 f.\tab}\pard\intbl\fi-360\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\ls2\ilvl0 Do you bath or shower?\par\pard\intbl\li851\tx540\tx851\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200      Bath \tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 Shower\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par{\listtext\pard\intbl\plain\f1\fs20 g.\tab}\pard\intbl\fi-360\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\ls2\ilvl0 Do you use slip resistant mats in the bath, bathroom or shower recess?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par{\listtext\pard\intbl\plain\f1\fs20 h.\tab}\pard\intbl\fi-360\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\ls2\ilvl0\plain\f1\fs20 Do you have a chair to sit on while drying yourself?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1701\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par{\listtext\pard\intbl\plain\f1\fs20 i.\tab}\pard\intbl\fi-360\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\ls2\ilvl0 Do you have grab rails fitted to your bathroom?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs12\par\page\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrr\brdrs\brdrw10\cellx5386\clvertalt\clbrdrl\brdrs\brdrw10\cellx10772\pard\widctlpar\intbl{\listtext\pard\intbl\plain\f1\fs20 j.\tab}\pard\intbl\fi-360\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\ls2\ilvl0\plain\f1\fs20 Can you carry meals easily and safely from the kitchen to your dining area?\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab            Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No   \plain\f2\fs36\loch\f2\hich\f2 \'a8\par{\listtext\pard\intbl\plain\f1\fs20 k.\tab}\pard\intbl\fi-360\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\ls2\ilvl0\plain\f1\fs20 Do you have difficulty gripping utensils or handrails?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920                 None     \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36    \plain\f1\fs20 A little     \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36    \plain\f1\fs20 A lot     \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\par{\listtext\pard\intbl\plain\f1\fs20 l.\tab}\pard\intbl\fi-360\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\ls2\ilvl0 Are the edges of the steps/stairs easily identifiable? \par\pard\intbl\li851\tx540\tx851\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab   Yes      \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par Do you have smoke detectors fitted to your home? \tab             Yes\tab   \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par{\listtext\pard\intbl\plain\f1\fs20 m.\tab}\pard\intbl\fi-360\li900\tx540\tx900\tx1080\tx1985\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\ls2\ilvl0 Do you have ambulance cover?\par\pard\intbl\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800                         Yes       \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No   \plain\f2\fs36\loch\f2\hich\f2 \'a8\par\plain\f1\fs20 Add any comments regarding feelings, nutrition or home safety issues\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\pard\intbl\tx540\tx2250\tx2700\tx3600\tx4680\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 13\tab Mobility / Activity\par\plain\f1\fs20\tab a.\tab Do you use a walking aid such as a walking stick, frame, wheelchair or motorised scooter?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20  \plain\f1\fs16 Specify\plain\f1\fs20  _______________ No \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1985\tx2694\tx2880\tx3240\tx3780\tx4395\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab b.\tab Do you need to hold on to furniture when moving around? \tab\par\tab\tab Yes      \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab    No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab c.\tab Do you have difficulty bending, kneeling\par\tab\tab or stooping?\par\tab\tab None  \plain\f2\fs36\loch\f2\hich\f2 \'a8 \plain\f1\fs20 A little \plain\f2\fs36\loch\f2\hich\f2 \'a8 \plain\f1\fs20 A lot    \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\plain\f1\fs20\tab d.    Do you have difficulty walking 4 house blocks?\par\tab\tab None  \plain\f2\fs36\loch\f2\hich\f2 \'a8 \plain\f1\fs20 A little \plain\f2\fs36\loch\f2\hich\f2 \'a8 \plain\f1\fs20 A lot    \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\plain\f1\fs20\tab e.     Do you have difficulty climbing one flight of stairs?\par\tab\tab None  \plain\f2\fs36\loch\f2\hich\f2 \'a8 \plain\f1\fs20 A little \plain\f2\fs36\loch\f2\hich\f2 \'a8 \plain\f1\fs20 A lot    \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\plain\f1\fs20\tab f.\tab Have you had a fall inside/outside the home\par\tab\tab in the past 3 months? \tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20 Comments\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab g.\tab Are you physically active (eg walking, gardening)?\par\tab\tab Never\tab\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Occasionally\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Regularly\tab\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\tx540\tx851\tx1080\tx1800\tx2070\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab h\tab Are you able to look after the inside of the house?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, easily\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs20\tab       Yes, with some difficulty       \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs24\cell\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3960\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\tab\tab Yes, with much difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\plain\f1\fs36\tab\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\tx540\tx851\tx1800\tx2070\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs20\tab i\tab Are you able to look after the outside of the house?\par\pard\intbl\li851\tx851\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520 Yes, easily\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, with some difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3960\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, with much difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\plain\f1\fs36\tab\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\tx540\tx851\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\plain\f1\fs20\tab j\tab Are you able to get to the shops?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, easily\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Yes, with some difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3960\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, with much difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs36\tab\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab k\tab Do you need help to bathe?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2520\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab\tab Independent\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\plain\f1\fs36\tab\tab\plain\f1\fs20 Needs some help\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab\tab Totally dependent\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2070\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab l\tab Do you need help to dress?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2520\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab\tab Independent\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\plain\f1\fs36\tab\tab\plain\f1\fs20 Needs some help\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab\tab Totally dependent\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2070\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab m\tab Do you need help to prepare food?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2520\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab\tab Independent\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\plain\f1\fs36\tab\tab\plain\f1\fs20 Needs some help\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab\tab Totally dependent\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2070\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab n\tab Do you need help to eat?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2520\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab\tab Independent\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\plain\f1\fs36\tab\tab\plain\f1\fs20 Needs some help\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab\tab Totally dependent\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2070\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab o\tab Are you able to hear the telephone?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, easily\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Yes, some problem\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3960\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, with much difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\plain\f1\fs36\tab\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\li540\tx540\tx1080\tx1800\tx2070\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs20 p     Are you able to use the telephone?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, easily\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Yes, with some difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3960\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, with much difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs36\tab     \plain\f1\fs20 No\tab                               \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs24\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs12\par\page\par\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrr\brdrs\brdrw10\cellx5386\clvertalt\clbrdrl\brdrs\brdrw10\cellx10772\pard\widctlpar\intbl\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2070\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab q.\tab Are you able to read newspapers and books?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, easily\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Yes, with some difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3960\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, with much difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\plain\f1\fs36\tab\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2070\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab r\tab Are you able to watch TV?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, easily\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Yes, with some difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3960\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, with much difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\plain\f1\fs36\tab\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2070\tx2520\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab s\tab Are you able to listen to music?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3780\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, easily\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Yes, with some difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx3240\tx3960\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab\tab Yes, with much difficulty\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\plain\f1\fs24\tab\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab t\tab Do you have any other interests?\par\pard\intbl\tx540\tx900\tx1080\tx3240\tx3960\tx4500\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par Specify ____________________________________\par\par\plain\f1\fs20\b 14 \tab Vision\par\pard\s6\intbl\tx540\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs20\tab Do you have problems with your eyesight?\par\pard\intbl\tx1080\tx1620\tx2880\tx3240\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\i\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab Comments\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 15\tab Hearing\par\plain\f1\fs20\tab Do you have problems with hearing?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes \tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs10\par\plain\f1\fs20\tab Comments\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par\pard\intbl\tx567\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs20\b 16\tab Oral Health\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab Do you have regular dental check-ups?\par\pard\intbl\li1276\tx540\tx900\tx1080\tx1276\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200 Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\li567\tx540\tx567\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200 Do you have dentures? \tab\par\pard\intbl\li1276\tx540\tx900\tx1080\tx1276\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200 Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab Comments\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par\pard\intbl\tx567\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs20\b 17\tab Feet\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab Do you have problems with one or both feet?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs10\par\plain\f1\fs20\tab Comments\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs20\b ________________________________________________\plain\f1\fs24\cell\pard\s2\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 18\tab Continence\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab a\tab Do you ever wet yourself?\par\tab\tab Never\tab\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Sometimes\tab\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Often\tab\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab b\tab Is this related to coughing or sneezing?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab c\tab How often do you go to the toilet at night?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab Never\tab\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Sometimes\tab\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab\tab Often\tab\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab d\tab Do you ever loose control of your bowels?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab e\tab Have you had a recent change of bowel habits?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab f\tab Do you have a family history of bowel cancer?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab Comments\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\pard\s3\intbl\fi-540\li540\tx540\tx1800\tx2700\tx3600\tx4680\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\plain\f1\fs20\par\plain\f1\fs20\b 19\tab Mental Status\par\pard\intbl\fi-540\li540\tx540\tx900\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20\tab a.\tab What is the \loch\f1\hich\f1 \'96\par\tab\tab year, season, date, day, month?\par\tab\plain\f1\fs20\i Score 1 point for each correct answer                    /5\plain\f1\fs20\par\tab b.\tab Where do you live?\par\tab\tab State, country, town, street number, street name\par\pard\s4\intbl\fi-540\li540\tx540\tx900\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20\i\tab Score 1 point for each correct answer                    /5\tab\par\tab\plain\f1\fs20 c.\tab Repeat 3 objects \loch\f1\hich\f1 \'96 house, bus, dog\par\pard\intbl\fi-540\li540\tx540\tx900\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20\tab\plain\f1\fs20\i Score 1 point per word on first trial only               /3\plain\f1\fs20\par\tab d.\tab Spell \loch\f1\hich\f1 \'91world\'92 backwards\par\tab\plain\f1\fs20\i Score 1 point for each correct letter                      /5\par\plain\f1\fs4\i\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20                /18\par\pard\intbl\fi-540\li540\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tab TOTAL score\par\par\tab Scale:   14 \loch\f1\hich\f1 \'96 18 indicates no cognitive difficulty\par\pard\intbl\qc\fi-540\li540\tx540\tx900\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs18\i If under 14, consider Mini Mental Questionnaire (Appendix A)\par\pard\intbl\fi-540\li540\tx540\tx900\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20 Comments\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs12\par\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs12\par\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrr\brdrs\brdrw10\cellx5386\clvertalt\clbrdrl\brdrs\brdrw10\cellx10772\pard\widctlpar\intbl\pard\intbl\tx567\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 20 \tab Other areas for examination and/or follow up\plain\f1\fs20  \par\pard\intbl\li284\tx284\tx567\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tab (\plain\f1\fs20\i e.g. skin, breast, prostate)\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs14\par\pard\intbl\fi-567\li567\tx540\tx567\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 21\tab Do you have sufficient support to continue living in your own home?\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\li567\tx540\tx567\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920 If no, what additional support would assist you to remain in your home?\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\pard\intbl\li567\tx567\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs36\par\plain\f1\fs20 Have you been assessed by the Aged Care Assessment Team (ACAT)?\par\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs4\par\plain\f1\fs16\par\plain\f1\fs20\tab If yes, when was the assessment?     \plain\f1\fs18 Date      /       /\par\pard\intbl\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs14\par\pard\intbl\li567\tx567\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20 What level of care was deemed appropriate for you at that time?\par\pard\intbl\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab Independent Living\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab Low Care\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab High Care\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\tx567\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab If no, would you like to be assessed?\par\pard\intbl\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs14\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 22 \tab Do you have any other concerns that we have not discussed?\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs36\par\plain\f1\fs20\b Summary\plain\f1\fs20  \par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\i (include agreed action/goals of patient and/or carer)\par\plain\f1\fs20\par I believe the patient would benefit from\par\tab Allied Health Assessment\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab      No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab Care Plan Yes\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab      No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371           Case Conference \tab\tab  Yes \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab  No \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs24\cell\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20 Other recommendations /comments\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\pard\s7\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\par\plain\f1\fs24\b Physical Examination\par\pard\s5\intbl\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f0\fs16\par\plain\f1\fs20\b 23\tab Patient\loch\f1\hich\f1 \'92s weight\tab                                              kg\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\par Comments\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\par\pard\intbl\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs20\b 24\tab Patient\loch\f1\hich\f1 \'92s height\tab                                             cm\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920 Comments\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\par\pard\s3\intbl\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs20\b 25\tab BMI\tab\tab\tab\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\par\pard\s3\intbl\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs20\b 26\tab BP/Pulses\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab\tab Blood Pressure \tab Systolic BP mm/Hg\par\plain\f1\fs10\par\plain\f1\fs20\tab\tab\tab\tab\tab Diastolic BP mm/Hg  \par\par\tab\tab Pulse Rate\tab\tab\tab\tab\tab\tab\par\par\tab\tab\tab\tab Regular\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 Irregular\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\plain\f1\fs10\par\plain\f1\fs20 Consider check for postural hypotension\par\tab\tab\tab\tab Yes\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab       No  \tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\par\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Comments \par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs24\b\par\plain\f1\fs20\b 27\tab Urinalysis (optional)\par\pard\intbl\tx540\tx900\tx1080\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\tab N.A.D\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab Glucose\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\tab Blood\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tab Protein\tab                               \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs24\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par\par\plain\f1\fs12\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrr\brdrs\brdrw10\cellx5386\clvertalt\clbrdrl\brdrs\brdrw10\cellx10772\pard\widctlpar\intbl\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 28\tab Vision\par\plain\f1\fs20\tab Acuity (with glasses)\tab\tab\tab\plain\f1\fs36\par\plain\f1\fs20\par\pard\s3\intbl\tx567\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs20\b 29\tab Hearing\par\pard\intbl\fi27\li851\tx851\tx1276\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20 a \tab Whisper Test\par\pard\intbl\li540\tx540\tx1276\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tab Heard      \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20    Not Heard \plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\li540\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs10\par\plain\f1\fs20 Comments _________________________________\par\pard\intbl\li851\tx851\tx1276\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs10\par\plain\f1\fs20 b\tab Check ear canals\par\pard\intbl\li540\tx540\tx1276\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tab Normal\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\tab\plain\f1\fs20 Abnormal\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\pard\intbl\li540\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs10\par\plain\f1\fs20 Comments _________________________________\par\plain\f1\fs10\par\pard\intbl\li851\tx851\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20 c\tab Hearing Aid\par\pard\intbl\li540\tx540\tx1418\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tab N/A\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\li1418\tx1418\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800 Adequate\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\fi360\li1080\tx1080\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Poor\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\plain\f1\fs10\par\pard\intbl\li540\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20 Comments _________________________________\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs10\par\pard\s3\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2835\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 30\tab Fitness to drive \par\pard\intbl\li1440\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\plain\f1\fs20 Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab       No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\plain\f0\fs24\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\tab\plain\f1\fs10\par\plain\f1\fs20\tab Date of last assessment              /        /\par\tab Refer to AustRoads Guidelines\par\par\pard\s3\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 31\tab Community / Allied Health Services\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs10\par\pard\intbl\qj\li540\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs20 Ask the patient if he or she is seeing or has seen any other GP/specialist/health worker or service provider in the last 6 months?\loch\f1\hich\f1 \'92\par\pard\intbl\fi540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 e.g.\par Aboriginal health worker\tab\tab Orthotist\par Audiologist\tab\tab\tab Personal carer\par\pard\intbl\li540\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360 Community nurse\tab\tab\tab Pharmacist\par Community care coordinator\tab\tab Physiotherapist\par Continence adviser\tab\tab\tab Podiatrist\par Daycare worker\tab\tab\tab Probation officer\par Dentist\tab\tab\tab\tab Prosthetist\par Dietitian\tab\tab\tab\tab Psychologist\par Health education provider\tab\tab Registered Nurse\par Home help service\tab\tab\tab Respite carer\par Home maintenance service\tab\tab Social worker\par Meals on Wheels\tab\tab\tab Specialist\par Occupational therapist\tab\tab Speech pathologist\par Optometrist\tab\tab\tab Transport provider\par Orthoptist\tab\tab\tab Other _________________\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par Details / Comments\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\par\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs20\b ________________________________________________\plain\f1\fs24\cell\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs24\b Future plan of action /referral\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs16\par\plain\f1\fs20\i (include agreed action/goals of patient and/or carer)\plain\f1\fs20\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs16\par\pard\intbl\fi27\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20 Care Plan\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 Case Conference\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\par\plain\f1\fs20 Allied Health Assessment\tab\tab\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\tab  \par\pard\intbl\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\par Name / Organisation______________________________\par\plain\f1\fs10\par\plain\f1\fs20 Address ________________________________________\par\plain\f1\fs10\par\plain\f1\fs20 _______________________________________________\par\plain\f1\fs10\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20 Telephone: _________________ Fax: ________________\par\pard\intbl\li567\tx567\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs10\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\par\pard\intbl\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920 Name / Organisation______________________________\par\plain\f1\fs10\par\plain\f1\fs20 Address ________________________________________\par\plain\f1\fs10\par\plain\f1\fs20 _______________________________________________\par\plain\f1\fs10\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20 Telephone: _________________ Fax: ________________\par\pard\intbl\li567\tx567\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs10\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\par\pard\intbl\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920 Name / Organisation______________________________\par\plain\f1\fs10\par\plain\f1\fs20 Address ________________________________________\par\plain\f1\fs10\par\plain\f1\fs20 _______________________________________________\par\plain\f1\fs10\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20 Telephone: _________________ Fax: ________________\par\pard\intbl\li567\tx567\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs10\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\par\pard\intbl\tx540\tx900\tx1080\tx1620\tx2160\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920 Name / Organisation______________________________\par\plain\f1\fs10\par\plain\f1\fs20 Address ________________________________________\par\plain\f1\fs10\par\plain\f1\fs20 _______________________________________________\par\plain\f1\fs10\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20 Telephone: _________________ Fax: ________________\par\pard\intbl\li567\tx567\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs10\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\par Comments / goals\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\par ________________________________________________\par\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs20\b\par ________________________________________________\plain\f1\fs24\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs12\par\page\par\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrr\brdrs\brdrw10\cellx5386\clvertalt\clbrdrl\brdrs\brdrw10\cellx10772\pard\widctlpar\intbl\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 32\tab\plain\f1\fs20 Have you made any arrangements for enduring power of attorney should it become necessary?\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab       No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\par Comment\par\par ________________________________________________\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs24\b\par\plain\f1\fs20\b 33\plain\f1\fs20\tab Have you made any arrangements for guardianship should it become necessary?\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab       No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\par Comment\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs20\b ________________________________________________\plain\f1\fs24\cell\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b 34\plain\f1\fs20\tab If you were to become terminally ill have you considered the level of medical intervention you would prefer?\par\pard\intbl\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tab\tab\tab Yes\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab       No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\tab\par Comment\par\pard\s2\intbl\tx540\tx2520\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\plain\f1\fs20\b\par ________________________________________________\par\par ________________________________________________\par\pard\intbl\qj\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\par\plain\f1\fs18\i You may wish to refer to the Schedule s 1 and 2 of the  \loch\f1\hich\f1 \'93Consent to medical treatment and Palliative Care Act 1995\'94\par\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx10772\pard\widctlpar\intbl\pard\intbl\qc\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b Patient and Doctor declaration\par\pard\intbl\tx270\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs24\tab\par\plain\f1\fs20 Date of assessment           \plain\f1\fs24      /       /\par\pard\intbl\fi-540\li540\tx270\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs20\par Patient\loch\f1\hich\f1 \'92s signature      \plain\f1\fs24   \par\par ______________________  \tab\tab\tab  /     /\plain\f1\fs20\par\pard\intbl\fi-900\li900\tx540\tx900\tx1080\tx1620\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\par Doctor\loch\f1\hich\f1 \'92s signature\par\par\pard\intbl\fi-540\li540\tx270\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\plain\f1\fs24 ______________________  \tab\tab\tab  /     /\plain\f1\fs20\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\par\pard\intbl\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3402\tx3969\tx4320\tx5040\tx5760\tx6480\tx7200 Review appointment needed? \par\pard\intbl\fi-540\li540\tx540\tx900\tx1701\tx1800\tx2340\tx2880\tx3240\tx3402\tx3969\tx4320\tx5040\tx5760\tx6480\tx7200\tab\tab Yes \tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs36\tab\plain\f1\fs20 Date       \plain\f1\fs24 /     /\tab\plain\f1\fs20 No\tab\plain\f2\fs36\loch\f2\hich\f2 \'a8\plain\f1\fs20\par\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\plain\f1\fs24\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par\pard\fi-540\li540\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b\par\pard\s8\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx10772\pard\widctlpar\intbl\pard\s8\intbl\qc\tx540\tx900\tx1080\tx1800\tx2340\tx2880\tx3240\tx3780\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\plain\f1\fs20\b General Practitioner/Local Medical Officer details\par\pard\intbl\fi-540\li540\tx540\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f0\fs24\par\plain\f1\fs20 Name: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Doctor:Name>>{\*\txfieldend}\plain\f1\fs20\par\par Address: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Doctor:Full Address>>{\*\txfieldend}\plain\f1\fs20\par\par Phone No.: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Doctor:Phone>>{\*\txfieldend}\plain\f1\fs20\par\par Provider No.: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Doctor:Provider Number>>{\*\txfieldend}\plain\f1\fs20\par\pard\intbl\cell\intbl\row\pard\pard\par\par\plain\f1\fs24\par\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par }