Carer Allowance - Medical Report for a person 16 years or over (SA332a) Instructions
This form contains 187 fields organized into 47 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Bladder/Bowel Control | ||
| checkbox_gyx26W_91ba | CheckBox | |
| checkbox_H0hPGL_9312 | CheckBox | |
| checkbox_s2Y0ZX_a450 | CheckBox | |
| checkbox_tOu21f_c186 | CheckBox | |
| Damage furniture, possessions or objects? | ||
| Often | Checkbox |
Check this box if your partner often damages furniture, possessions, or objects. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes damages furniture, possessions, or objects. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Never | Checkbox |
Check this box if your partner never damages furniture, possessions, or objects. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Date of Hospitalisation | ||
| Hospitalisation Day | Date |
Enter the day of your partner's hospitalisation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Hospitalisation Year | Date |
Enter the year of your partner's hospitalisation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Hospitalisation Month | Date |
Enter the month of your partner's hospitalisation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Deliberately harm themselves? | ||
| checkbox_o8Ioi3_363f | CheckBox | |
| checkbox_tDuevW_16a9 | CheckBox | |
| checkbox_t7gWg7_bca9 | CheckBox | |
| Difficulty Hearing Others | ||
| Always | Checkbox |
Check this box if your partner always has difficulty hearing others, even when using hearing aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Often | Checkbox |
Check this box if your partner often has difficulty hearing others, even when using hearing aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes has difficulty hearing others, even when using hearing aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Never | Checkbox |
Check this box if your partner never has difficulty hearing others, even when using hearing aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Difficulty Seeing Clearly | ||
| Never | Checkbox |
Check this box if your partner never has difficulty seeing clearly, even with glasses. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes has difficulty seeing clearly, even with glasses. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Often | Checkbox |
Check this box if your partner often has difficulty seeing clearly, even with glasses. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| checkbox_EAFh9m_4b28 | CheckBox | |
| Dressing Ability | ||
| Without help | Checkbox |
Check this box if the person can dress themselves without any assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With some help | Checkbox |
Check this box if the person requires some assistance to dress themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With a lot of help | Checkbox |
Check this box if the person requires extensive assistance to dress themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Cannot do this | Checkbox |
Check this box if the person is completely unable to dress themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Eating Ability | ||
| Cannot feed themselves | Checkbox |
Check this box if the person is unable to feed themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With a lot of help | Checkbox |
Check this box if the person needs a lot of help to eat their food. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With some help | Checkbox |
Check this box if the person needs some help to eat their food. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Without help | Checkbox |
Check this box if the person can eat their food without any help. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Education/Training Details | ||
| Education Training Nights | Number |
Enter the number of nights your partner spends at a training centre or hostel. Fill only if 'checkbox_bMqPaV_50d1' is 'Yes'.
Depends on:
checkbox_bMqPaV_50d1
|
| Education Training Start Day | Text |
Enter the day your partner started staying overnight for education or training. Fill only if 'checkbox_bMqPaV_50d1' is 'Yes'.
Depends on:
checkbox_bMqPaV_50d1
|
| Education Training Start Month | Text |
Enter the month your partner started staying overnight for education or training. Fill only if 'checkbox_bMqPaV_50d1' is 'Yes'.
Depends on:
checkbox_bMqPaV_50d1
|
| Education Training Start Year | Number |
Enter the year your partner started staying overnight for education or training. Fill only if 'checkbox_bMqPaV_50d1' is 'Yes'.
Depends on:
checkbox_bMqPaV_50d1
|
| Expected Release Date | ||
| Expected Release Day | Text |
Please provide the day of your partner's expected release from the hospital. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Expected Release Year | Text |
Please provide the year of your partner's expected release from the hospital. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Expected Release Month | Text |
Please provide the month of your partner's expected release from the hospital. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Fall Over Indoors Or Outdoors | ||
| Never | Checkbox |
Check this box if your partner never falls over indoors or outdoors, or from a wheelchair. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes falls over indoors or outdoors, or from a wheelchair. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Often | Checkbox |
Check this box if your partner often falls over indoors or outdoors, or from a wheelchair. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| General | ||
| text_8b88_1cc9 | Text | |
| text_27f2_ed25 | Text | |
| text_4ed4_516c | Text | |
| text_23a1_2165 | Text | |
| text_9354_9604 | Text | |
| text_rMwxBT_645f | Text | |
| text_uJindl_9202 | Text | |
| text_eeVoGa_756a | Text | |
| Grooming | ||
| Cannot groom | Checkbox |
Check this box if your partner is completely unable to look after their grooming (e.g., shaving, caring for hair, teeth). Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Grooming with a lot of help | Checkbox |
Check this box if your partner requires substantial assistance to look after their grooming (e.g., shaving, caring for hair, teeth). Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Grooming with some help | Checkbox |
Check this box if your partner requires a small amount of assistance to look after their grooming (e.g., shaving, caring for hair, teeth). Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Grooming without help | Checkbox |
Check this box if your partner can look after their grooming (e.g., shaving, caring for hair, teeth) completely independently, without any assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Have unusual, inappropriate or repetitive behaviours? | ||
| Often | Checkbox |
Check this box if the partner often exhibits unusual, inappropriate or repetitive behaviours. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if the partner sometimes exhibits unusual, inappropriate or repetitive behaviours. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Never | Checkbox |
Check this box if the partner never exhibits unusual, inappropriate or repetitive behaviours. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Help Or Attention During The Night | ||
| Never | Checkbox |
Check this box if the person never needs help or attention during the night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if the person sometimes needs help or attention during the night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Often | Checkbox |
Check this box if the person often needs help or attention during the night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Always | Checkbox |
Check this box if the person always needs help or attention during the night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| In-Hospital Care Details | ||
| No | Checkbox |
Check this box if you do not provide care for your partner while they are in hospital. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if you provide care for your partner while they are in hospital, such as being involved in their rehabilitation or treatment. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Description of Care Provided | Text |
Please provide details about the care you provide for your partner while they are in the hospital. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Laugh or cry without apparent reason? | ||
| Never | Checkbox |
Check this box if your partner never laughs or cries without apparent reason. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes laughs or cries without apparent reason. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Often | Checkbox |
Check this box if your partner often laughs or cries without apparent reason. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Medication Care | ||
| Does not take medication | Checkbox |
Check this box if the partner does not take any medication. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Cannot do this | Checkbox |
Check this box if the partner is unable to take care of their own medication at all. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Without help | Checkbox |
Check this box if the partner takes care of their own medication entirely without any assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With some help | Checkbox |
Check this box if the partner requires some assistance to take care of their own medication. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With a lot of help | Checkbox |
Check this box if the partner requires a lot of assistance to take care of their own medication. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Move Around The House | ||
| Is confined to bed | Checkbox |
Check this box if your partner is unable to move around and is confined to bed. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Without help | Checkbox |
Check this box if your partner can move around the house independently, without any assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With help of one person | Checkbox |
Check this box if your partner requires assistance from one person to move around the house. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With help of two people | Checkbox |
Check this box if your partner requires assistance from two people to move around the house. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Move To And From Bed, Chairs, Wheelchair And Walking Aids | ||
| With a lot of help | Checkbox |
Check this box if the person requires significant physical assistance, guidance, or supervision to move to and from bed, chairs, wheelchair, and walking aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Cannot do this | Checkbox |
Check this box if the person is completely unable to move to and from bed, chairs, wheelchair, and walking aids, even with assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With some help | Checkbox |
Check this box if the person requires some physical assistance, guidance, or supervision to move to and from bed, chairs, wheelchair, and walking aids. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Without help | Checkbox |
Check this box if the person can move to and from bed, chairs, wheelchair, and walking aids independently, without any assistance or supervision. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Other Care Details | ||
| Other Care - Nights | Text |
Enter the number of nights your partner stays overnight for 'Other care' reasons, such as temporary care or respite care. Fill only if 'checkbox_yoMiAv_5bc1' is 'Yes'.
Depends on:
checkbox_yoMiAv_5bc1
|
| Other Care - Start Day | Text |
Enter the day the 'Other care' arrangement started. Fill only if 'checkbox_yoMiAv_5bc1' is 'Yes'.
Depends on:
checkbox_yoMiAv_5bc1
|
| Other Care - Start Month | Text |
Enter the month the 'Other care' arrangement started. Fill only if 'checkbox_yoMiAv_5bc1' is 'Yes'.
Depends on:
checkbox_yoMiAv_5bc1
|
| Other Care - Start Year | Text |
Enter the year the 'Other care' arrangement started. Fill only if 'checkbox_yoMiAv_5bc1' is 'Yes'.
Depends on:
checkbox_yoMiAv_5bc1
|
| Overnight Stay Status | ||
| Yes | Checkbox |
Check this box if your partner does stay overnight or longer with another person or organisation on a regular basis.
|
| No | Checkbox |
Check this box if your partner does not stay overnight or longer with any other person or organisation on a regular basis.
|
| Page 9 | ||
| Month | Text |
Enter the month (MM) of the date of signing. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'Yes'.
Depends on:
Yes
|
| Year | Text |
Enter the year (YYYY) of the date of signing. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'Yes'.
Depends on:
Yes
|
| Day | Text |
Enter the day (DD) of the date of signing. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'Yes'.
Depends on:
Yes
|
| Signature | Text |
Enter your signature in this field. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'Yes'.
Depends on:
Yes
|
| Partner Hospitalization Status | ||
| No | Checkbox |
Check this box if your partner is not currently in a hospital.
|
| Yes | Checkbox |
Check this box if your partner is currently in a hospital.
|
| Partner's ability to communicate feelings and wants | ||
| Never able to communicate feelings and wants | Checkbox |
Check this box if your partner is never able to let others know how they feel and what they want. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes able to communicate feelings and wants | Checkbox |
Check this box if your partner is sometimes able to let others know how they feel and what they want. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Usually able to communicate feelings and wants | Checkbox |
Check this box if your partner is usually able to let others know how they feel and what they want. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Always able to communicate feelings and wants | Checkbox |
Check this box if your partner is always able to let others know how they feel and what they want. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Partner's ability to remember today's events | ||
| Never | Checkbox |
Check this box if your partner never remembers things that happened today. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| checkbox_WIuHU5_ed5c | CheckBox | |
| Usually | Checkbox |
Check this box if your partner usually remembers things that happened today. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes remembers things that happened today. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Partner's ability to understand other people | ||
| Never | Checkbox |
Check this box if your partner never understands what other people say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes understands what other people say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Usually | Checkbox |
Check this box if your partner usually understands what other people say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Always | Checkbox |
Check this box if your partner always understands what other people say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Partner's ability to understand the carer | ||
| Never understands carer | Checkbox |
Check this box if your partner never understands what you, the carer, say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes understands carer | Checkbox |
Check this box if your partner sometimes understands what you, the carer, say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Usually understands carer | Checkbox |
Check this box if your partner usually understands what you, the carer, say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Always understands carer | Checkbox |
Check this box if your partner always understands what you, the carer, say. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Partner's awareness of their location | ||
| Always | Checkbox |
Check this box if your partner always knows where they are. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Usually | Checkbox |
Check this box if your partner usually knows where they are. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes knows where they are. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Never | Checkbox |
Check this box if your partner never knows where they are. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Partner's awareness of time of day | ||
| Always | Checkbox |
Check this box if your partner always knows whether it is morning, afternoon, or night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Usually | Checkbox |
Check this box if your partner usually knows whether it is morning, afternoon, or night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes knows whether it is morning, afternoon, or night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Never | Checkbox |
Check this box if your partner never knows whether it is morning, afternoon, or night. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Partner's Main Disability/Medical Condition | ||
| Partner's Main Condition | Text |
Please describe your partner's main disability or medical condition(s) for which they require care.
|
| Personal Care Details | ||
| No | Checkbox |
Check this box if you do not personally provide daily care for your partner due to a disability or medical condition. Fill only if 'What is your partner's main disability/medical condition(s) for which they require care?' is filled
Depends on:
Partner's Main Condition
|
| Yes | Checkbox |
Check this box if you personally provide daily care for your partner due to a disability or medical condition. Fill only if 'What is your partner's main disability/medical condition(s) for which they require care?' is filled
Depends on:
Partner's Main Condition
|
| Care Start Day | Date |
Please enter the day the personal care started. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Care Start Year | Date |
Please enter the year the personal care started. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Care Start Month | Date |
Please enter the month the personal care started. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Physically harm other people? | ||
| Often | Checkbox |
Check this box if your partner often physically harms other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes physically harms other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Never | Checkbox |
Check this box if your partner never physically harms other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Post-Hospital Care Arrangement | ||
| No | Checkbox |
Check this box if your partner will not return to your care after being released from the hospital. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if your partner will return to your care after being released from the hospital. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Reason for Overnight Stay | ||
| checkbox_YRrWWf_f32d | CheckBox |
Depends on:
Yes
|
| checkbox_bMqPaV_50d1 | CheckBox |
Depends on:
Yes
|
| checkbox_yoMiAv_5bc1 | CheckBox |
Depends on:
Yes
|
| checkbox_eLoRiW_c61b | CheckBox |
Depends on:
Yes
|
| Shared Care Details | ||
| Number of Nights for Shared Care | Number |
Enter the number of nights the partner stays overnight due to shared care. Fill only if 'checkbox_eLoRiW_c61b' is 'Yes'.
Depends on:
checkbox_eLoRiW_c61b
|
| Shared Care Start Date Day | Text |
Enter the day of the month when shared care started. Fill only if 'checkbox_eLoRiW_c61b' is 'Yes'.
Depends on:
checkbox_eLoRiW_c61b
|
| Shared Care Start Date Month | Text |
Enter the month when shared care started. Fill only if 'checkbox_eLoRiW_c61b' is 'Yes'.
Depends on:
checkbox_eLoRiW_c61b
|
| Shared Care Start Date Year | Text |
Enter the year when shared care started. Fill only if 'checkbox_eLoRiW_c61b' is 'Yes'.
Depends on:
checkbox_eLoRiW_c61b
|
| Shout, scream at or threaten, other people? | ||
| Often | Checkbox |
Check this box if your partner often shouts, screams at, or threatens other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes shouts, screams at, or threatens other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Never | Checkbox |
Check this box if your partner never shouts, screams at, or threatens other people. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Showering/Bathing Ability | ||
| Without help | Checkbox |
Check this box if the person can shower or bathe themselves independently, without any assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With some help | Checkbox |
Check this box if the person requires some assistance to shower or bathe themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With a lot of help | Checkbox |
Check this box if the person requires extensive assistance to shower or bathe themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Cannot do this | Checkbox |
Check this box if the person is unable to shower or bathe themselves even with assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Terminal Illness Status | ||
| No | Checkbox |
Check this box if your partner is not terminally ill or is expected to live for more than 3 months.
|
| Yes | Checkbox |
Check this box if your partner is terminally ill and is expected to live for 3 months or less.
|
| Toilet Use Ability | ||
| Without help | Checkbox |
Check this box if the person can use the toilet completely independently without any assistance. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With some help | Checkbox |
Check this box if the person needs some assistance, such as supervision or minor physical support, to use the toilet. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| With a lot of help | Checkbox |
Check this box if the person requires significant physical support or extensive assistance from another person to use the toilet. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Cannot use a toilet | Checkbox |
Check this box if the person is unable to use a toilet, regardless of the level of assistance provided. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Treatment Care | ||
| Treatment Without Help | Checkbox |
Check this box if the partner takes care of their own treatment without any help. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Treatment With Some Help | Checkbox |
Check this box if the partner takes care of their own treatment with some help. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Treatment With A Lot of Help | Checkbox |
Check this box if the partner takes care of their own treatment with a lot of help. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Cannot Take Care of Treatment | Checkbox |
Check this box if the partner is unable to take care of their own treatment. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| No Treatment | Checkbox |
Check this box if the partner does not currently receive or require any treatment. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Treatment Details | ||
| Number of Nights for Treatment | Text |
Please provide the total number of nights your partner stays for treatment. Fill only if 'checkbox_YRrWWf_f32d' is 'Yes'.
Depends on:
checkbox_YRrWWf_f32d
|
| Treatment Start Day | Text |
Please provide the day of the month when your partner's treatment started. Fill only if 'checkbox_YRrWWf_f32d' is 'Yes'.
Depends on:
checkbox_YRrWWf_f32d
|
| Treatment Start Month | Text |
Please provide the month when your partner's treatment started. Fill only if 'checkbox_YRrWWf_f32d' is 'Yes'.
Depends on:
checkbox_YRrWWf_f32d
|
| Treatment Start Year | Text |
Please provide the year when your partner's treatment started. Fill only if 'checkbox_YRrWWf_f32d' is 'Yes'.
Depends on:
checkbox_YRrWWf_f32d
|
| Use of Continence Aids/Equipment | ||
| With some help | Checkbox |
Check this box if the person uses continence aids or equipment but requires some assistance. Fill only if 'checkbox_tOu21f_c186' is not 'Never'.
Depends on:
checkbox_tOu21f_c186
|
| With a lot of help | Checkbox |
Check this box if the person uses continence aids or equipment and requires a lot of assistance. Fill only if 'checkbox_tOu21f_c186' is not 'Never'.
Depends on:
checkbox_tOu21f_c186
|
| Does not use aids | Checkbox |
Check this box if the person does not use any continence aids or equipment. Fill only if 'checkbox_tOu21f_c186' is not 'Never'.
Depends on:
checkbox_tOu21f_c186
|
| Without help | Checkbox |
Check this box if the person uses continence aids or equipment independently, without requiring any assistance. Fill only if 'checkbox_tOu21f_c186' is not 'Never'.
Depends on:
checkbox_tOu21f_c186
|
| Wander away or 'run away' from home? | ||
| Never | Checkbox |
Check this box if your partner never wanders away or 'runs away' from home. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes wanders away or 'runs away' from home. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Often | Checkbox |
Check this box if your partner often wanders away or 'runs away' from home. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Withdraw from contact with other people, or appear depressed, worried or fearful? | ||
| Never | Checkbox |
Check this box if your partner never withdraws from contact with other people, or appears depressed, worried or fearful. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Sometimes | Checkbox |
Check this box if your partner sometimes withdraws from contact with other people, or appears depressed, worried or fearful. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Often | Checkbox |
Check this box if your partner often withdraws from contact with other people, or appears depressed, worried or fearful. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Your Details | ||
| Title | Text |
Please enter your title, such as Mr, Mrs, Ms, Dr, or Other.
|
| Family Name | Text |
Please enter your family name.
|
| First Given Name | Text |
Please enter your first given name.
|
| Other Given Name(s) | Text |
Please enter any other given names you may have.
|
| Date of Birth Year | Number |
Please enter the year of your birth.
|
| Date of Birth Month | Text |
Please enter the month of your birth.
|
| Female | Checkbox |
Check this box if your gender is female.
|
| Other | Checkbox |
Check this box if your gender is not male or female.
|
| Male | Checkbox |
Check this box if your gender is male.
|
| Phone Number | Text |
Please enter the main part of your contact phone number.
|
| Phone Number Area Code | Text |
Please enter the area code or the first part of your contact phone number.
|
| checkbox_49e8_4655 | CheckBox | |
| Date of Birth Day | Text |
Please enter the day of your birth.
|
| Your Partner's Details | ||
| Partner's Title | Text |
Enter your partner's title, such as Mr, Mrs, Ms, Dr, or Other.
|
| Partner's Family Name | Text |
Enter your partner's family name.
|
| Partner's First Given Name | Text |
Enter your partner's first given name.
|
| Partner's Other Given Names | Text |
Enter any other given names your partner may have.
|
| Partner's Birth Day | Date |
Enter the day of your partner's birth.
|
| Partner's Birth Year | Date |
Enter the year of your partner's birth.
|
| Partner's Birth Month | Date |
Enter the month of your partner's birth.
|
| Male | Checkbox |
Check this box if your partner identifies as male.
|
| Female | Checkbox |
Check this box if your partner identifies as female.
|
| Other | Checkbox |
Check this box if your partner identifies with a gender other than male or female.
|