Personal Care Form Personal Care Step 1 of 12 8% Participant - DetailsParticipant's Name(Required) First Last Email of the person completing the form(Required) Participant - Personal CareAssistance - Clean Teeth Yes No Please provide more informationAssistance - Fill a bath or run a shower Yes No Please provide more informationAssistance – Shaving Yes No Please provide more informationAssistance - Washing Hair Yes No Please provide more informationAssistance - Washing Hands Yes No Please provide more informationAssistance dressing Yes No Please provide more informationHot Water Awareness Yes No Please provide more informationManage Buttons, Zippers, etc. by self Yes No Please provide more informationSpecial Bath Oil, Shampoo, Soap Yes No Please provide more informationSupervision Required Whilst Bathing Yes No Please provide more information Participant - Bedtime RoutineContinence Aids to Bed Yes No More detailsIndicates when wants to go to bed Yes No More detailsProblems sleeping away from normal residence Yes No More detailsSleeps with Bedroom Door Closed Yes No More detailsSleeps with Light On Yes No More detailsSleeps in a Single Room Yes No More detailsSpecial Sleeping Needs (e.g. two pillows, etc.) Yes No More detailsRe-positioned during night Yes No More detailsSleep through the night Yes No More detailsOther helpful Bedtime information such as bedtime routine (Specify) Participant - Behaviour SupportAbsconding / Wandering Yes No Additional information about my behaviours and when this usually occursAbusive Language / Swearing Yes No Additional information about my behaviours and when this usually occursAggression Yes No Additional information about my behaviours and when this usually occursCrying / Screaming / Other Noisy Behaviours Yes No Additional information about my behaviours and when this usually occursEating Non-Edible Substance Yes No Additional information about my behaviours and when this usually occursNon-Compliance Yes No Additional information about my behaviours and when this usually occursProperty Damage Yes No Additional information about my behaviours and when this usually occursObsessive / Repetitive Yes No Additional information about my behaviours and when this usually occursSelf-Injuries Yes No Additional information about my behaviours and when this usually occursSelf-Stimulatory Behaviour (thumb sucking, rocking etc.) Yes No Additional information about my behaviours and when this usually occursOther Behaviours Yes No How are these behaviours managed?Behaviour Support Plan(Required) Yes No Pending NotesPlease attached Behaviour support Plan(Required)Max. file size: 128 MB. Participant - CommunicationPlease describe how the participant communicatesCommunication method Compic Proloquo2Go/Ipad Facial Expression Non-Verbal Pictures Signs Speech Vocalisation Other Other communication methodCommunication Plan Available Yes No Please upload the latest speech therapy report(Required)Max. file size: 128 MB. Additional information that you might need to know about how I communicate:AngerHappinessHungerPainSadnessThirstToiletingWriting Community AccessList the hobbies, interests, activities, and places that bring you joy and help you feel happy or fulfilled.List any activities, situations, or places you don’t enjoy or that make you feel uncomfortable or unhappy.Additional Resources or Supports Required Yes No More detailsAttend School/Vocation Yes No Name of School/VocationFears or Phobias Yes No More details (e.g closed spaces, escalators)Public Transport with Support Staff Yes No What supports are required during public transport- ie- hold hand, supervision, assistance entering ferry, taxi, bus, train, etc.Require Activities whilst Travelling ( e.g. Books, Music, etc.) Yes No More Information While Travelling...Road Safety - is the Client Aware? Yes No More detailsTravel Sickness Yes No More detailsPocket Money on Outings Yes No More detailsRemains Seated Whilst Travelling Yes No More detailsRemoves Seatbelt Whilst Travelling Yes No More detailsSwimming/Water Sports Incontinence Yes No More detailsSwimming/Water Sports Independent/Support Required Yes No More details Participant - Eating, Drinking & MealtimesLikes - Food and Drinks:Dislikes - Food and Drinks:Assistance with Eating or Drinking Yes No More DetailsCultural or Religious Food Practices Yes No More DetailsEncouragement to Eat Yes No More DetailsFood Allergies / Adverse Reactions Yes No More DetailsLeft or Right Handed Left Handed Right Handed Eats independently Yes No More detailsMeals served Chopped Mashed Normal Pureed Other OtherDoes your child have a meal management plan? Yes No Please upload your meal management plan(Required)Max. file size: 128 MB. Special Aids for Eating or Drinking Yes No More detailsSpecial Diet Requirements Yes No More DetailsUtensil used Bowl Cut out cup Fingers Fork Spoon Plastic spoon only Straw/cup Other Other Participant - MenstruationMenstruation Yes No Duration of cycle (days)Sanitary Products used Participant - Mobility and MovementDifficulty moving on Uneven or Rough Ground Yes No More detailsHearing or Vision Impaired Yes No More detailsMobility Level Fully mobile needs assistance to walk uses other aids uses wheelchair slight physical disability More detailsSpecial Aids Required (e.g. Glasses, Helmets, Orthodontics, Other Splints, Walking Frame, Wheelchair, etc.)Travelling in a Vehicle (special seating required) Participant - Swimming and Water SportIndependently Swim Yes No More detailsParticipate in Swimming or Water Sports Yes No More detailsWheelchair Access Required Yes No Support whilst in Water Yes No How? One on One Two to One Participant - ToiletingAssistance Required - Toilet Paper Yes No More detailsAssistance Required - Washing Hands Yes No More detailsAssistance - Special Aids or Equipment Yes No More detailsAware of needing to use toilet Yes No More detailsConstipation - Any Signs, Symptoms or Behaviour changes Yes No More detailsFully Independent Toileting Yes No More detailsInappropriate Behaviours Relating to Toileting Yes No More detailsIncontinent Yes No More detailsPreferred Ways of Toileting Yes No More detailsRoutine - Day TimeRoutine - Night TimeToilet Timed Yes No More detailsUse Continent Aids Yes No More detailsIs there any additional information you’d like to share that could help us provide the best possible support ConsentI give authority(Required) I give authority for the organisation; to collect, store, use and disclose personal and sensitive information, including health records, for the primary purpose of service provision and directly related needs in accordance with the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) whilst I/we remain a participant of this organisation. If my/our circumstances change I agree to notify St Anthony’s Family Care as soon as practicable.(Required)I understand that(Required) I understand that this may include personal information under the Freedom of Information and Protection of Privacy Act and personal health information under the Health Information Protection Act.(Required)I also understand that(Required) I also understand that only the minimum necessary information will be shared to address my concern, in accordance with the limitations and protections set out in these Acts.(Required)Collection and Use of Personal Information - terms and conditions I confirm that the information(Required) I confirm that the information provided in this form is true and correct to the best of my knowledge. I understand this form may be completed on behalf of the person named above.(Required)Name of person completing the form(Required) First Relationship to participant(Required)Date(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature(Required)
