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Nurses and Care Support Workers
Heartbeat Healthcare Facilities
Disability Support Services
Home and Community Care
Useful Links and Information
Brochures
Contact Us
Register For Work
Client Wellness Report Form
2018-09-20T20:54:51+10:00
Client's Name
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First
Last
Your Full Name
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First
Last
Service Date
*
Date Format: DD slash MM slash YYYY
Full Shift Time
*
Please enter your start and finish shift times.
Personal Care
Do you currently assist the client with Personal Care
*
Please check the most appropriate
Yes
No
N/A
If yes, please tick the most appropriate level of assistance they require
*
Full assist
Partial assist
Standby
If yes, please tick the most appropriate level of assistance they require Have there been any changes in the ability of the client to carry out their personal care?
*
Yes the client is improving and is becoming more independent with their personal care needs
Yes, the client is declining in health and requires more assistance
No change
Is there anything that you should let us know about, do you have any concerns? If yes please note down a brief account.
Domestic Assistance
Do you currently assist the client with domestic assistance?
*
Please check the most appropriate
Yes
No
N/A
If yes, please briefly describe the assistance requested.
*
Is there anything that you should let us know about? Do you have any environmental concerns for the client’s safety and cleanliness?
Has there been any change in the ability of the client regarding their Domestic service needs?
*
Yes the client is improving and is becoming more independent with their domestic needs
Yes the client is declining in health and requires more assistance
No improvement or changes
Shopping
Do you currently assist the client with shopping?
*
Yes
No
If yes, please note any improvements or concerns that you may have noticed.
*
Mobility
Please describe the client’s ability to mobilise.
*
Improved
Decreased
No change
Does the client have mobility aids?
*
E.g.: stick, rolator frame, shower chair, etc
Yes, client using all aids successfully
No, client resistant to using aids
N/A, no aids required
Please document any mobility concerns you may have for this client.
Clients Welfare
Do you currently assist client with social support?
*
Yes
No
Comment:
Are they living on their own?
*
Yes
No
Comment:
Do you have any concerns for the welfare of the client?
*
Yes
No
Comment:
Dietary needs – do they appear to have adequate fresh food?
*
Yes
No
Comment:
Is their environment safe and clean?
*
Yes
No
Comment:
If there is anything further you would like to say, please comment below.
Additional comments or concerns: