Template: Assessment Tool

Template: Assessment Tool

ASSESSMENT TOOL
Client’s name:
Date of Birth:
Address:

Choose
1. Move around the house (may use walking stick, frame. Wheel Without help
chair etc)?
With help of one
person
With help of two
people
Is confined to bed
2. Fall over indoors or outdoors? Often
Sometimes
Never
3. Have difficulty hearing others (even with hearing aids)? Always
Often
Sometimes
Never
4. Have difficulty seeing clearly (even with glasses)? Always
Often
Sometimes
Never
5. Need help or attention during the night? Always
Often
Sometimes
Never
6. Use continence aids or equipment (e.g. catheter)? Without help
With some help
With a lot of help
Does not use aids

Template: Assessment Tool – Version 1.0 Institute of Health and Nursing Australia
Dated: October 2017 ABN: 59 106 800 944 | RTO ID: 21985 | CRICOS Code:03386G
Page 2 of 3 www.ihna.edu.au
 Template: Assessment Tool

7. Use the toilet? Without help

With some help
With a lot of help
Bed ridden
8. Takes care of his own medications (e.g. takes the right tablet at Without help
right time)?
With some help
With a lot of help
Cannot do this
Does not take
medicines
9. Understand what the carer says? Always
Usually
Sometimes
Never
10. Remember things that happen today? Always
Usually
Sometimes
Never
11. Know where he or she is? Always
Usually
Sometimes
Never
12. Shout, scream or threaten other people? Always
Usually
Sometimes
Never

Template: Assessment Tool – Version 1.0 Institute of Health and Nursing Australia
Dated: October 2017 ABN: 59 106 800 944 | RTO ID: 21985 | CRICOS Code:03386G
Page 3 of 3 www.ihna.edu.au