Client Wellness Report Form

Client's Name*

Prefix First Last

Your Full Name*

Prefix First Last

Service Date*

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: