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{\footerf\pard\plain\f2\fs16\par}\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs28\b\ul\par\pard\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs56\b\ul Annual Health Assessment\plain\f1\fs24\b\ul\par\plain\f1\fs20 For patients 75 and over\par Aboriginla and Torres Strait Islander 55 and over\par To be conducted by the patient's usual GP\par\trowd\trgaph30\trleft6\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1927\clvertalt\cellx3351\clvertalt\cellx6081\clvertalt\cellx7708\clvertalt\cellx9635\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\plain\f1\fs20\b All Non-ATSI\cell\cell ATSI\cell\plain\f1\fs20\cell\intbl\row\pard\trowd\trgaph30\trleft6\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1927\clvertalt\cellx3351\clvertalt\cellx6081\clvertalt\cellx7708\clvertalt\cellx9635\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b Item numbers\plain\f1\fs20\cell Practice\cell Home\cell Practice\cell Home\cell\intbl\row\pard\trowd\trgaph30\trleft6\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1927\clvertalt\cellx3351\clvertalt\cellx6081\clvertalt\cellx7708\clvertalt\cellx9635\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell Item 700 \plain\f3\fs28 p\plain\f1\fs20\cell Item 702  \plain\f3\fs28 p\plain\f1\fs20\cell Item 704  \plain\f3\fs28 p\plain\f1\fs20\cell Item 706  \plain\f3\fs28 p\plain\f1\fs20\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b GP details:\plain\f1\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Doctor:Name>>{\*\txfieldend}\plain\f1\fs20\par\par\plain\f1\fs24\b Signature:\plain\f1\fs20 ___________________________________\cell\plain\f1\fs24\b\ul Date:\plain\f1\fs24  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Miscellaneous:Date (long)>>{\*\txfieldend}\plain\f1\fs24\b\par\plain\f1\fs20\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\par\plain\f1\fs24\b\ul Patient's Name:\plain\f1\fs24\b\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Patient Demographics:Full Details>>{\*\txfieldend}\plain\f1\fs24\b\par\plain\f1\fs24\b\ul\par Past History:\plain\f1\fs24\b\par{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfieldbin\txfielddata 0000}{\*\txfieldtext \plain\f1\fs24 <<Clinical Details:History List>>}}\plain\f1\fs24\par\plain\f1\fs24\b\par\plain\f1\fs24\b\ul Allergies:\plain\f1\fs24\b\par{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfieldbin\txfielddata 0000}{\*\txfieldtext \plain\f1\fs24 <<Clinical Details:Allergies>>}}\plain\f1\fs24\b\par\par\plain\f1\fs24\b\ul Smoking:\plain\f1\fs24\b\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Clinical Details:Smoking>>{\*\txfieldend}\plain\f1\fs24\b\par\par\plain\f1\fs24\b\ul Alcohol:\plain\f1\fs24\b\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Clinical Details:Alcohol>>{\*\txfieldend}\plain\f1\fs24\b\par\plain\f1\fs24\b\ul\par Social History:\plain\f1\fs24\b\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Clinical Details:Social History>>{\*\txfieldend}\plain\f1\fs24\b\par\par\plain\f1\fs24\b\ul Family History:\plain\f1\fs24\b\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Clinical Details:Family History>>{\*\txfieldend}\plain\f1\fs24\b\par\par\plain\f1\fs24\b\ul Hearing:\plain\f1\fs24\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\plain\f1\fs24\b\ul Vision:\plain\f1\fs24\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\par\plain\f1\fs24\b\ul Progress notes:\plain\f1\fs36\b\ul\par\pard\ri2\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Summary:Progress Note (Current)>>{\*\txfieldend}\plain\f0\fs20\par\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\par\plain\f1\fs24\b\ul Medications:\plain\f1\fs24\b\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Clinical Details:Medication List>>{\*\txfieldend}\plain\f1\fs24\b\par\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2076\clvertalt\cellx9632\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Side effects\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2076\clvertalt\cellx9632\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Interactions\plain\f1\fs24\b\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2076\clvertalt\cellx9632\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Suggested changes\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2076\clvertalt\cellx9632\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Webster pack\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2076\clvertalt\cellx9632\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx1814\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360 Carer gives medications\cell Yes No\cell\intbl\row\pard\pard\tx720\tx1440\tx1814\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\plain\f1\fs24\b\ul\par Immunisations:\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Clinical Details:Immunisation List>>{\*\txfieldend}\plain\f1\fs24\b\par\par\plain\f1\fs24\b\ul Investigations\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Summary:Investigation Results (Selected)>>{\*\txfieldend}\plain\f1\fs24\par\plain\f1\fs24\b\par\plain\f1\fs36\b HEALTH ASSESSMENT\plain\f1\fs24\b\par\par\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\ul Examination/Observations\plain\f1\fs24\b :\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1746\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Weight:\plain\f1\fs24\b\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1746\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Blood Pressure:\plain\f1\fs24\b\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1746\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Pulse:\plain\f1\fs24\b\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1746\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Rhythmn:\plain\f1\fs24\b\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1746\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Ears:\plain\f1\fs24\b\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1746\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Other:\plain\f1\fs24\b\cell\cell\intbl\row\pard\pard\tx720\tx1440\tx1814\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\ul Medical Support\plain\f1\fs24\ul\par\plain\f1\fs24 Have you seen any other doctor/specialist in the last six months?\cell\par Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you get regular health care from any other source?\par{\pntext\pard\intbl\plain\f4\fs24\'b7\tab}\pard\intbl\fi-283\li340\sa120\tx340\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls1\ilvl0{\*\pn\pnlvlblt\ilvl0\ls1\pnstart1\pnf4\pnfs24\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}Allied/Pharmacist/Alternative/Other\plain\f1\fs24\ul\cell\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\plain\f1\fs24 Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\ul Social Support\plain\f1\fs24\par In the last four weeks was there anyone available to help you if you wanted or needed help?\par{\pntext\pard\intbl\plain\f4\fs24\'b7\tab}\pard\intbl\fi-283\li340\sa120\tx340\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls1\ilvl0{\*\pn\pnlvlblt\ilvl0\ls1\pnstart1\pnf4\pnfs24\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}Paid/Unpaid-volunteer/Adequacy \cell\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\par\par Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Are you responsible for caring for someone else?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you receive any community services?\par{\pntext\pard\intbl\plain\f4\fs24\'b7\tab}\pard\intbl\fi-283\li340\sa120\tx340\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls1\ilvl0{\*\pn\pnlvlblt\ilvl0\ls1\pnstart1\pnf4\pnfs24\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}Meals on Wheels/\loch\f1\hich\f1 \'92Home Help\'92/etc\cell\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you need any community services?\par{\pntext\pard\intbl\plain\f4\fs24\'b7\tab}\pard\intbl\fi-283\li340\sa120\tx340\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls1\ilvl0{\*\pn\pnlvlblt\ilvl0\ls1\pnstart1\pnf4\pnfs24\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}Transport/dressing/bathing/housework/shopping/meals/telephone/garden/other\cell\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\ul Personal Wellbeing Assessment\plain\f1\fs17\par\plain\f1\fs24 In the last four weeks have you been troubled by problems such as feeling anxious or very unhappy?\plain\f1\fs17\cell\plain\f1\fs24\par Yes No\plain\f1\fs17\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Do you sometimes have difficulty sleeping?\tab\plain\f1\fs24\ul\cell\plain\f1\fs24 Yes No  \cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Have you had any problems with continence? \par{\pntext\pard\intbl\plain\f4\fs24\'b7\tab}\pard\intbl\fi-283\li340\sa120\tx340\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls1\ilvl0{\*\pn\pnlvlblt\ilvl0\ls1\pnstart1\pnf4\pnfs24\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}Bowels/Urine/Related to coughing or sneezing\cell\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you experience any problems with your feet?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\ul Home Safety Assessment\plain\f1\fs24\ul\par\plain\f1\fs24 Can you easily get up from seats and lounge chairs?\plain\f1\fs24\ul\cell\par\plain\f1\fs24 Yes No\plain\f1\fs24\ul\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Can you easily get in and out of bed?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Can you reach and switch on a light from your bed?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you have floor mats and are they fixed safely?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you use slip resistant mats in the bathroom?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Arthritis: do you have problems with handles, lifting, etc?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Are there stairs/steps that you have difficulty with?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you need grab rails in your\par{\pntext\pard\intbl\plain\f4\fs24\'b7\tab}\pard\intbl\fi-283\li340\sa120\tx340\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\ls1\ilvl0{\*\pn\pnlvlblt\ilvl0\ls1\pnstart1\pnf4\pnfs24\pnb0\pni0\pnstrike0\pnul0\pncf0\pncb0{\pntxtb \'b7}}Bathroom/toilet/entry/stairs/steps/other?\cell\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\ul Personal Mobility Assessment\plain\f1\fs24\par Can you bend and kneel?\cell\par Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Can you climb a full flight of stairs?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Can you walk a hundred metres?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Can you bath and dress yourself?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Have you had a fall in the last three months?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\ul Personal Nutrition Assessment\plain\f1\fs24\par Do you eat three meals a day?\cell\par Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you eat fruit and vegetables most days?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you eat dairy most days?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you have six or more 8 cups of fluid most days?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you have problems swallowing, eating or your teeth?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you have any health problems that affect the kind of food you eat?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Do you always have enough money for food?\cell Yes No\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5670\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Have you lost or gained five kilos or more within the last six months and if so for what reasons?\cell Yes No\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\ul Psychological Assessment\plain\f1\fs24\b :\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx3291\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Memory\plain\f1\fs24\b\cell\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx3291\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Folstein MMSE\plain\f1\fs24\b\cell           \plain\f1\fs24  /30\plain\f1\fs24\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx3291\clvertalt\cellx9628\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24 Depression\plain\f1\fs24\b\cell   \plain\f1\fs24 Yes No\plain\f1\fs24\b\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b\ul\par Fitness for driving:\plain\f1\fs24\b\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\par\plain\f1\fs28\b\ul Recommendations:\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par }