Integrated Assessment Tool (IAT) Offline Form 2506 Instructions

Check this box if you are able to take a bath or shower independently.

Check this box if you are able to take a bath or shower with some difficulty or assistance.

Check this box if you are unable to take a bath or shower.

Check this box if you can hardly ever talk about your deepest problems with at least some of your family and friends.

Check this box if you can talk about your deepest problems with at least some of your family and friends some of the time.

Check this box if you can talk about your deepest problems with at least some of your family and friends most of the time.

Check this box if you are able to dress yourself independently without any difficulty.

Check this box if you are somewhat able to dress yourself, perhaps with some difficulty or partial assistance.

Check this box if you are unable to dress yourself and require full assistance.

Check this box if you are fully able to drive or take public transport.

Check this box if you are somewhat able to drive or take public transport, indicating some difficulty or limitation.

Check this box if you are unable to drive or take public transport.

Check this box if you are able to get to places out of walking distance.

Check this box if you are somewhat able to get to places out of walking distance.

Check this box if you are not able to get to places out of walking distance.

Check this box if the client can get to places out of walking distance without help.

Check this box if the client needs some help to get to places out of walking distance.

Check this box if the client is completely unable to get to places out of walking distance.

Check this box if the patient is less able to manage money and financial affairs.

Check this box if the patient is not less able to manage money and financial affairs.

Check this box if it is unknown whether the patient is less able to manage money and financial affairs.

Check this box if the question about the patient's ability to manage money and financial affairs is not applicable.

Check this box if the patient is less able to manage their medication independently.

Check this box if the patient is not less able to manage their medication independently.

Check this box if it is unknown whether the patient is less able to manage their medication independently.

Check this box if the question regarding the patient's ability to manage medication independently is not applicable.

Check this box if you are able to prepare meals independently.

Check this box if you are somewhat able to prepare meals, possibly with some difficulty or assistance.

Check this box if you are unable to prepare meals.

Check this box if you are able to shop for groceries on your own.

Check this box if you are somewhat able to shop for groceries on your own.

Check this box if you are not able to shop for groceries on your own.

Check this box if you are able to transfer yourself from a chair, bed, etc. without any assistance.

Check this box if you are able to transfer yourself from a chair, bed, etc. with the help of an aid.

Check this box if you are somewhat able to transfer yourself from a chair, bed, etc., possibly requiring some assistance or difficulty.

Check this box if you are not able to transfer yourself from a chair, bed, etc.

Check this box if you are able to undertake housework.

Check this box if you are somewhat able to undertake housework.

Check this box if you are not able to undertake housework.

Check this box if you are able to go to the toilet, wipe, and re-dress independently.

Check this box if you are somewhat able to go to the toilet, wipe, and re-dress, possibly requiring some assistance.

Check this box if you are not able to go to the toilet, wipe, and re-dress at all or require significant assistance.

Check this box if you are able to walk without any difficulty.

Check this box if you are able to walk with some difficulty or require assistance.

Check this box if you are unable to walk.

Check this box if the person does not identify as Aboriginal and does not identify as Torres Strait Islander.

Check this box if the person identifies as Aboriginal.

Check this box if the person identifies as Torres Strait Islander.

Check this box if the person identifies as both Aboriginal and Torres Strait Islander.

Check this box if the person's Aboriginal and/or Torres Strait Islander identity is not stated or is inadequately described.

Check this box if the person did not correctly close their eyes as instructed.

Check this box if the person correctly closed their eyes as instructed.

Check this box if the participant's response to the pointing task (item 8) is incorrect.

Check this box if the participant's response to the pointing task (item 8) is partially correct or warrants a score of 1.

Check this box if the participant's response to the pointing task (item 8) is fully correct.

Please describe how the client is currently completing this functional activity, including details of any assistance or supervision received, who provides it, what support is provided, and for how long the client has received it.

Provide additional details regarding how the client completes the functional activity, including any assistance received, who provides it, what support is provided, and the duration of the support.

Provide detailed information regarding how the client is currently completing this functional activity, including any physical health impacts, assistance received, who provides the support, what support is provided, and the period of time the client has received the support for.

Provide additional details regarding the client's eating, including how they complete this activity, any assistance or supervision received, and specifics about the support provided, such as who provides it, what is provided, and the period of time it has been received for.

Provide additional details on how the client handles money, including current functional activity, assistance received (who provides support, what support, and for how long), and any supervision from others.

Provide additional details regarding how the client completes light housework, including any assistance received, who provides it, what support is given, and the period of time for which support has been received.

Provide any additional details regarding the client's medication or injection support, including who provides the support, what support is provided, and the period of time the client has received the support.

Provide additional details regarding the support received for transfers, including who provides the support, what support is provided, and the period of time the client has received this support.

Check this box if the client has an Advanced Care Plan.

Check this box if the client does not have an Advanced Care Plan.

Provide details about the client's Advanced Care Plan.

Check this box if you are afraid that something bad is going to happen to you.

Check this box if you are not afraid that something bad is going to happen to you.

Check this box if it is not possible to determine the frequency of the client's verbal aggressive behaviour, such as yelling, screaming, or threatening.

Check this box if the client never exhibits verbal aggressive behaviour, such as yelling, screaming, or threatening.

Check this box if the client occasionally exhibits verbal aggressive behaviour, such as yelling, screaming, or threatening.

Check this box if the client regularly exhibits verbal aggressive behaviour, such as yelling, screaming, or threatening.

Check this box if the client always exhibits verbal aggressive behaviour, such as yelling, screaming, or threatening.

Check this box if it is not possible to determine the frequency of the client's agitation.

Check this box if the client never experiences agitation.

Check this box if the client occasionally experiences agitation.

Check this box if the client regularly experiences agitation.

Check this box if the client always experiences agitation.

Check this box if the client never has six or more alcoholic drinks on one occasion.

Check this box if the client has six or more alcoholic drinks on one occasion less than monthly.

Check this box if the client has six or more alcoholic drinks on one occasion monthly.

Check this box if the client has six or more alcoholic drinks on one occasion weekly.

Check this box if the client has six or more alcoholic drinks on one occasion daily or almost daily.

Please provide further details about the client's alcohol consumption frequency if they consume six or more alcoholic drinks on one occasion 'Less than monthly', 'Monthly', 'Weekly', or 'Daily or almost daily'.

Check this box if the client has or has had allergies and/or sensitivities.

Check this box if the client does not have and has not had any allergies or sensitivities.

Provide detailed information about the client's identified allergies and/or sensitivities to environment, medication, or food.

Check this box if the level of anxiety cannot be determined.

Check this box if the client experiences anxiety never.

Check this box if the client experiences anxiety occasionally.

Check this box if the client experiences anxiety regularly.

Check this box if the client experiences anxiety always.

Provide any further details regarding wheelchair independence, assistance required, or specific limitations.

Check this box if it is not possible to determine the level of apathy experienced.

Check this box if there is a complete absence or suppression of passion, emotion, or excitement, indicating apathy, that has never occurred.

Check this box if there is an occasional absence or suppression of passion, emotion, or excitement, indicating apathy.

Check this box if there is a regular absence or suppression of passion, emotion, or excitement, indicating apathy.

Check this box if there is always an absence or suppression of passion, emotion, or excitement, indicating apathy.

Enter the name(s) of the person(s) or organisation(s) who provided assessment information, their relationship to the client, and their contact details, if not the client.

Check this box if the assessment's primary location is the client's home, or the client's location if the assessment occurs over-the-phone or via tele-health.

Check this box if the assessment's primary location is the carer's home, or the client's location if the assessment occurs over-the-phone or via tele-health.

Check this box if the assessment's primary location is another community setting, such as an Aboriginal Medical Centre, or the client's location if the assessment occurs over-the-phone or via tele-health.

Check this box if the assessment's primary location is a private hospital, or the client's location if the assessment occurs over-the-phone or via tele-health.

Check this box if the assessment's primary location is a public hospital, or the client's location if the assessment occurs over-the-phone or via tele-health.

Check this box if the assessment's primary location is another private hospital inpatient setting, or the client's location if the assessment occurs over-the-phone or via tele-health.

Check this box if the assessment's primary location is another public hospital inpatient setting, or the client's location if the assessment occurs over-the-phone or via tele-health.

Check this box if the assessment's primary location is a clinic, or the client's location if the assessment occurs over-the-phone or via tele-health.

Check this box if the assessment's primary location is a residential aged care service, or the client's location if the assessment occurs over-the-phone or via tele-health.

Enter any additional details related to the assessment setting.

Provide any medical domain notes related to the assessment.

Please provide any relevant notes from the assessor.

Please provide any additional notes from the assessor regarding the assessment.

Provide detailed notes from the assessor regarding the client's falls, including the number of falls, causes, contributing factors, location, injuries, medical attention, GP awareness, falls clinic attendance, and fear of falling.

Provide detailed notes from the assessor regarding the client's behaviours, including experienced changes, when they occurred, their impact on daily tasks and quality of life, assistance received, and the source of this information.

Provide any additional notes from the assessor regarding the client's cognitive assessment.

Enter the assessor's detailed notes regarding the client's current medications, how they are administered, the source of medication information, the client's compliance, and any over-the-counter or non-prescription medications used.

Provide the assessor's comments about the trigger.

Enter any relevant notes or observations from the assessor.

Provide detailed notes from the assessor regarding the client's caring relationship, including the type and frequency of support, recent changes, difficulties, and specific considerations for the carer and client.

Check this box if it is not possible to determine whether the client exhibits at-risk behaviour.

Check this box if the client never exhibits at-risk behaviour.

Check this box if the client occasionally exhibits at-risk behaviour.

Check this box if the client regularly exhibits at-risk behaviour.

Check this box if the client always exhibits at-risk behaviour.

Check this box if no one provides assistance to the client for taking a bath or shower.

Check this box if an informal carer or carers provide assistance to the client for taking a bath or shower.

Check this box if an aged care service provider or providers assist the client with taking a bath or shower.

Check this box if someone other than those listed provides assistance to the client for taking a bath or shower.

Enter the details of the 'Other' helper for bath/shower assistance.

Check this box if the client's need for bathing or showering is completely unmet.

Check this box if the client's need for bathing or showering is partially met.

Check this box if the client's need for bathing or showering is completely met.

Check this box if the client does not require assistance with bathing or showering.

Check this box if the person can take a bath or shower independently without any assistance.

Check this box if the person requires some assistance to take a bath or shower.

Check this box if the person is completely unable to take a bath or shower, requiring full assistance or unable to perform the task.

Provide additional details regarding the client's bathing and showering activities, including current methods, impacts on ability, any assistance received, who provides support, what support is given, and the period of time for which support has been received.

Check this box if the subject scores 0 for opening the bottle and pouring water into the cup.

Check this box if the subject scores 1 for opening the bottle and pouring water into the cup.

Check this box if the client is continent regarding bowel function.

Check this box if the client experiences occasional bowel accidents, approximately once per week.

Check this box if the client is incontinent regarding bowel function or requires an enema.

Check this box if the person is unable to bend their knees and lift their bottom clear of the bed for the bridge task.

Check this box if the person is able to bend their knees and lift their bottom clear of the bed for the bridge task.

Provide the full name of the carer.

Provide the telephone number of the carer.

Check this box if the person helping the client lives with the client.

Check this box if the person helping the client does not live with the client.

Please provide the full name of the carer.

Please provide the telephone number of the carer.

Check this box if the carer has full-time paid employment.

Check this box if the carer has part-time paid employment.

Check this box if the carer does not have any paid employment.

Provide details of the carer's relationship to the client if 'Other' was selected.

Check this box if the person the client is caring for is 65 years old or older and is not an Aboriginal or Torres Strait Islander.

Check this box if the person the client is caring for is 50 years old or older and is an Aboriginal or Torres Strait Islander.

Check this box if the person the client is caring for is 45 years old or older, is an Aboriginal or Torres Strait Islander, and is experiencing homelessness or at risk due to housing stress or not having secure accommodation.

Check this box if the person the client is caring for is 50 years old or older, is not an Aboriginal or Torres Strait Islander, and is experiencing homelessness or at risk due to housing stress or not having secure accommodation.

Check this box if the person the client is caring for does not meet any of the specified criteria above.

Check this box if the person the client is caring for falls into a category not listed in the options above.

Check this box if the person cared for is 65 years old or older and is not an Aboriginal or Torres Strait Islander.

Check this box if the person cared for is 50 years old or older and is an Aboriginal or Torres Strait Islander.

Check this box if the person cared for is 45 years old or older, is an Aboriginal or Torres Strait Islander, and is experiencing homelessness or at risk due to housing stress or not having secure accommodation.

Check this box if the person cared for is 50 years old or older, is not an Aboriginal or Torres Strait Islander, and is experiencing homelessness or at risk due to housing stress or not having secure accommodation.

Check this box if the person cared for does not meet any of the criteria listed in the options above.

Check this box if the person cared for falls into a category not explicitly listed above.

Check this box if the client's garden requires mowing and/or other gardening tasks like weeding or hedging.

Check this box if the client's garden only requires mowing.

Check this box if the client's garden requires only gardening tasks such as weeding or hedging, but not mowing.

Check this box if the client does not have a garden.

Check this box if the client's house is a single storey property with no steps inside or outside the home.

Check this box if the client's house is a single storey property with some internal or external steps.

Check this box if the client's house is a multi-storey property with stairs.

Check this box if the client's house is a multi-storey property with stairs, and also has a chair lift or elevation in the home.

Check this box if the client is able to complete the Revised Faecal Incontinence Scale (RFIS).

Check this box if the client is not able to complete the Revised Faecal Incontinence Scale (RFIS).

Please enter the type of the client's address.

Please provide the full address of the client.

Check this box if the client's bowel incontinence severity is occasional.

Check this box if the client's bowel incontinence severity is mild.

Check this box if the client's bowel incontinence severity is moderate.

Check this box if the client's bowel incontinence severity is severe.

Enter the client's gender.

Enter the client's ethnicity.

Enter the client's marital status.

Enter the client's preferred language.

Enter the client's country of birth.

Check this box if the client identifies as having a culturally and linguistically diverse background.

Check this box if the client identifies as an Aboriginal and/or Torres Strait Islander person.

Check this box if the client identifies as living in a rural or remote area.

Check this box if the client identifies as financially or socially disadvantaged.

Check this box if the client identifies as a Veteran.

Check this box if the client identifies as homeless.

Check this box if the client identifies as being at risk of homelessness.

Check this box if the client identifies as a lesbian, gay, bisexual, transgender, or intersex person.

Check this box if the client identifies as a person separated from their parents or children by forced adoption or removal.

Check this box if the client identifies as a socially isolated individual.

Check this box if the client identifies with none of the above categories and wishes to specify another.

Please specify the details of the client's diversity if they identify as 'Other'.

Check this box if the client does not drive a motor vehicle.

Check this box if the client experiences aggression, agitation, or has been found wandering.

Check this box if the client does not experience aggression, agitation, or has not been found wandering.

Please provide the client's Aged Care ID.

Please provide the client's date of birth.

Please provide the client's Medicare Card number.

Please provide the client's DVA (Department of Veterans' Affairs) number.

Check this box if the client is managing their bowel incontinence issue.

Check this box if the client is not managing their bowel incontinence issue.

Please provide the client's first name.

Please provide the client's last name.

Check this box if the client needs help to communicate, either to understand or be understood by others.

Check this box if the client does not need help to communicate, meaning they can understand and be understood by others without assistance.

Check this box if the client is supporting or looking after another person, such as assisting with their activities of daily living and/or self-care tasks.

Check this box if the client is not supporting or looking after another person.

Check this box if the client is able and willing to complete the Revised Urinary Incontinence Scale (RUIS).

Check this box if the client is not able or willing to complete the Revised Urinary Incontinence Scale (RUIS).

Check this box if the client is capable of making their own decisions.

Check this box if the client is not capable of making their own decisions.

Check this box if the client's employment status is performing home duties.

Check this box if the client's employment status is retired due to age.

Check this box if the client's employment status is retired due to disability.

Check this box if the client's employment status is not listed as Home duties, Retired for age, or Retired for disability.

Check this box if the client's experience of the circumstance began with a recent acute illness or event.

Check this box if the client's experience of the circumstance has been a gradual increase in needs over time.

Check this box if the client's experience of the circumstance is due to a long-term disability.

Check this box if the client's experience of the circumstance does not fit the other categories and requires specific explanation.

Please specify the 'Other' circumstance regarding the client's experience.

Check this box if the client has experienced stressful events over the past three months and you need to provide more details.

Check this box if the client has not experienced any stressful events over the past three months.

Provide details of the stressful events the client has experienced over the past three months.

Check this box if the person can climb stairs independently without needing any assistance.

Check this box if the person can climb stairs but requires some assistance, such as using handrails, a cane, or crutches.

Check this box if the person is completely unable to climb stairs.

Check this box if the client correctly marked the clock hands to show 10 minutes past eleven o'clock.

Check this box if the client incorrectly marked the clock hands to show 10 minutes past eleven o'clock.

Check this box if the client correctly marked all numbers to indicate the hours of a clock with correct spacing.

Check this box if the client incorrectly marked all numbers to indicate the hours of a clock or used incorrect spacing.

Check this box if the user received a score of 0 for demonstrating how to use the comb.

Check this box if the user received a score of 1 for demonstrating how to use the comb.

Provide any additional comments or observations here, limited to 300 characters.

Provide any additional comments or details about the circumstance.

Please provide any additional comments or information in this field.

Check this box if an informal carer or carers help the client use other communication devices.

Check this box if an aged care service provider or providers help the client use other communication devices.

Check this box if someone other than those listed helps the client use other communication devices.

Check this box if the client can use other communication devices effectively without any assistance.

Check this box if the client needs some assistance (e.g., special device or help with specific functions) to use other communication devices effectively.

Check this box if the client is completely unable to use other communication devices.

Check this box if the communications need is completely unmet.

Check this box if the communications need is completely met.

Check this box if the client does not require assistance regarding their communications need.

Provide any additional details regarding how the communications need is being met, considering factors such as difficulty in operating devices, contacting individuals, using basic functions, making calls, or taking photos.

Check this box if you feel connected to the Aboriginal community all the time.

Check this box if you feel connected to the Aboriginal community most of the time.

Check this box if you feel connected to the Aboriginal community sometimes.

Check this box if you feel connected to the Aboriginal community not much.

Check this box if you feel connected to the Aboriginal community never.

Check this box if the user's answer for the community or place name is incorrect.

Check this box if the user's answer for the community or place name is correct.

Check this box if the user provides an incorrect answer for the community or place name.

Check this box if the user provides a correct answer for the community or place name.

Check this box if you want to complete the Geriatric Depression Scale (GDS).

Check this box if you do not want to complete the Geriatric Depression Scale (GDS).

Check this box if it is not possible to determine if the client experiences confusion.

Check this box if the client never experiences confusion.

Check this box if the client occasionally experiences confusion.

Check this box if the client regularly experiences confusion.

Check this box if the client always experiences confusion.

Enter the client's email address.

Enter the client's mobile phone number.

Enter any other relevant phone number for the client.

Check this box if you feel you spend enough time connecting to country all the time.

Check this box if you feel you spend enough time connecting to country most of the time.

Check this box if you feel you spend enough time connecting to country sometimes.

Check this box if you feel you do not spend much time connecting to country.

Check this box if you feel you never spend enough time connecting to country.

Check this box if the "Boomerang" image was one of the items previously shown to the client.

Check this box if the "Emu/Bird/Horse" image was one of the items previously shown to the client.

Check this box if the "Boomerang/Hatchet/Stick" image was one of the items previously shown to the client.

Check this box if the "Dog/Fish/Crocodile" image was one of the items previously shown to the client.

Check this box if the "Man/Woman/Boy" image was one of the items previously shown to the client.

Check this box if the "Hat/Tan/Billy+Fire" image was one of the items previously shown to the client.

Check this box if the client correctly identified 0 pictures with cues during the cued recall task.

Check this box if the client correctly identified 1 picture with cues during the cued recall task.

Check this box if the client correctly identified 2 pictures with cues during the cued recall task.

Check this box if the client correctly identified 3 pictures with cues during the cued recall task.

Check this box if the client correctly identified 4 pictures with cues during the cued recall task.

Check this box if the client correctly identified 5 pictures with cues during the cued recall task.

Check this box if you feel connected to cultural ways all the time.

Check this box if you feel connected to cultural ways most of the time.

Check this box if you feel connected to cultural ways sometimes.

Check this box if you do not feel connected to cultural ways much.

Check this box if you never feel connected to cultural ways.

Check this box if you are currently receiving aged care services.

Check this box if you are not currently receiving aged care services.

Check this box if you are not sure whether you are currently receiving aged care services.

Provide details of the aged care services the client is currently receiving.

Provide a detailed description of all current services that are in place.

Enter the date of first contact with the client for the purposes of conducting an assessment.

Provide the date when the triage was conducted.

Check this box if the client correctly recalled the date during the assessment.

Check this box if the client incorrectly recalled the date during the assessment.

Check this box if the client never experiences delirium.

Check this box if the client occasionally experiences delirium.

Check this box if the client regularly experiences delirium.

Check this box if the client always experiences delirium.

Check this box if the client has a confirmed dementia diagnosis from a geriatrician or neurologist.

Check this box if the client does not have a confirmed dementia diagnosis from a geriatrician or neurologist.

Provide a detailed description of the person the client is supporting.

Provide a detailed description of the person the client is supporting.

Provide a detailed description of the types of support the client provides.

Provide a detailed description of the types of support the client provides.

Check this box if you currently smoke and desire to be a smoker.

Check this box if you currently smoke but do not desire to be a smoker.

Record the profession of each clinician or professional person, assessment organisation member or non-team member that contributes to the Comprehensive Assessment of the client.

Check this box if the client experiences any difficulties with sleep, such as difficulty falling asleep, fragment sleep, or insufficient sleep.

Check this box if the client does not experience any difficulties with sleep.

Please provide details about any difficulties experienced with sleep, such as difficulty falling asleep, fragment sleep, or insufficient sleep.

Check this box if the patient has more difficulty in finding the right word or tends to use the wrong words more often when speaking.

Check this box if the patient does not have more difficulty in finding the right word or does not tend to use the wrong words more often when speaking.

Check this box if it is unknown whether the patient has more difficulty in finding the right word or tends to use the wrong words more often when speaking.

Check this box if the question regarding the patient's difficulty in finding words is not applicable.

Check this box if the client has had difficulty walking 300m or around the block by themselves and without aids in the past 4 weeks.

Check this box if the client has not had difficulty walking 300m or around the block by themselves and without aids in the past 4 weeks.

Check this box if, in the past 4 weeks, the user has had difficulty walking up 10 steps by themselves and without using aids, without resting.

Check this box if, in the past 4 weeks, the user has not had difficulty walking up 10 steps by themselves and without using aids, without resting.

Check this box if it is not possible to determine the level of disorientation regarding people, such as family or friends.

Check this box if the person is never disoriented regarding people, such as family or friends.

Check this box if the person is occasionally disoriented regarding people, such as family or friends.

Check this box if the person is regularly disoriented regarding people, such as family or friends.

Check this box if the person is always disoriented regarding people, such as family or friends.

Check this box if it is not possible to determine the frequency with which the person is unable to identify the time, day, date, or year.

Check this box if the person is never unable to identify the time, day, date, or year.

Check this box if the person is occasionally unable to identify the time, day, date, or year.

Check this box if the person is regularly unable to identify the time, day, date, or year.

Check this box if the person is always unable to identify the time, day, date, or year.

Check this box if the extent of the persistent difficulty in initiating or maintaining sleep cannot be determined.

Check this box if there is never a persistent difficulty in initiating or maintaining sleep.

Check this box if there is occasionally a persistent difficulty in initiating or maintaining sleep.

Check this box if there is regularly a persistent difficulty in initiating or maintaining sleep.

Check this box if there is always a persistent difficulty in initiating or maintaining sleep.

Check this box if the person helping lives with the client.

Check this box if the person helping does not live with the client.

Check this box if the individual does not do things that are wrong in an Aboriginal way.

Check this box if the individual sometimes does things that are wrong in an Aboriginal way.

Check this box if the individual always does things that are wrong in an Aboriginal way.

Check this box if the client can complete the dressing task independently without any assistance.

Check this box if the client requires some assistance or supervision to complete the dressing task.

Check this box if the client is completely unable to perform the dressing task.

Provide any additional details regarding how the client completes the dressing activity, including details of assistance received, who provides support, the type of support, and the duration of the support.

Check this box if the client does not receive assistance from anyone for dressing.

Check this box if the client receives assistance for dressing from informal carers, such as family, friends, or neighbours.

Check this box if the client receives assistance for dressing from an aged care service provider.

Check this box if the client receives assistance for dressing from a source not listed above, then specify who helps in the 'If 'Other', please specify' field.

Provide specific details about the dressing assistance provider if 'Other' was selected.

Check this box if the client's dressing need is completely unmet.

Check this box if the client's dressing need is partially met.

Check this box if the client's dressing need is completely met.

Check this box if the client does not require assistance with dressing.

Check this box if the client's partner assists them in getting to places out of walking distance.

Check this box if the client's parent assists them in getting to places out of walking distance.

Check this box if another family member assists the client in getting to places out of walking distance.

Check this box if a friend or neighbour assists the client in getting to places out of walking distance.

Check this box if public transport assists the client in getting to places out of walking distance.

Check this box if a taxi assists the client in getting to places out of walking distance.

Check this box if an aged care provider transport service assists the client in getting to places out of walking distance.

Check this box if another type of provider or method assists the client in getting to places out of walking distance.

Check this box if you have dropped many of your activities or interests.

Check this box if you have not dropped many of your activities or interests.

Check this box if you have used an illegal or prescriptive drug for non-medical reasons once or twice in the past year.

Check this box if you have used an illegal or prescriptive drug for non-medical reasons monthly in the past year.

Check this box if you have used an illegal or prescriptive drug for non-medical reasons weekly in the past year.

Check this box if you have used an illegal or prescriptive drug for non-medical reasons daily or almost daily in the past year.

Check this box if the client's need for assessment has gradually increased over time.

Check this box if the client's circumstance is related to a long term disability.

Check this box if the client's circumstance duration is not covered by the other options.

Provide details on how long the client has experienced the 'Other' circumstance.

Check this box if the individual has a DVA White Card.

Check this box if the individual has a DVA Gold Card.

Check this box if the individual has a DVA Orange Card.

Check this box if the individual does not have any DVA Entitlement or it is not applicable.

Check this box if the client is able to feed themselves completely without any assistance.

Check this box if the client needs some assistance to feed themselves.

Check this box if the client is completely unable to feed themselves.

Check this box if the client does not receive help with eating from anyone.

Check this box if an informal carer provides help to the client with eating.

Check this box if an aged care service provider helps the client with eating.

Check this box if someone other than those listed provides help to the client with eating.

Provide details of the 'Other' help provider(s) for eating.

Enter the name of the eighth health condition.

Provide a detailed description of the eighth health condition.

Indicate whether the eighth health condition has been diagnosed, and by whom.

Check this box if the eighth listed health condition is the primary health condition, meaning it has the greatest impact on the person's need for assistance with activities of daily living and social participation.

Check this box if the client is not at risk of, suspected of, or confirmed to be experiencing elder abuse.

Check this box if financial elder abuse is a suspected or confirmed type of abuse.

Check this box if physical elder abuse, including restraint, is a suspected or confirmed type of abuse.

Check this box if emotional elder abuse is a suspected or confirmed type of abuse.

Check this box if sexual elder abuse is a suspected or confirmed type of abuse.

Check this box if social elder abuse is a suspected or confirmed type of abuse.

Check this box if elder abuse in the form of neglect is a suspected or confirmed type of abuse.

Check this box if another type of elder abuse, not specifically listed, is suspected or confirmed, and provide further details.

Provide a detailed description if 'Other' type of elder abuse is suspected or confirmed.

Check this box if you feel you can share your knowledge and stories with the younger generation all the time.

Check this box if you feel you can share your knowledge and stories with the younger generation most of the time.

Check this box if you feel you can share your knowledge and stories with the younger generation sometimes.

Check this box if you feel you cannot share your knowledge and stories with the younger generation very much.

Check this box if you feel you can never share your knowledge and stories with the younger generation.

Check this box if an emergency care plan has been developed.

Check this box if an emergency care plan has not been developed.

Specify details about the emergency care plan, including other family members, people to contact, short-term care, long-term care options, or other support options.

Enter the title of the emergency contact, such as Mr., Ms., Dr., etc.

Enter the given name (first name) of the emergency contact.

Enter the surname (last name) of the emergency contact.

Enter the relationship of the emergency contact to the client, such as spouse, parent, sibling, friend, etc.

Enter the email address of the emergency contact.

Enter the mobile phone number of the emergency contact.

Enter an alternative phone number for the emergency contact.

Enter the type of address for the emergency contact, such as residential or postal.

Enter the full street address of the emergency contact.

Check this box if the client has emotional or mental health issues that significantly limit their self-care capacity, requiring intensive supervision and/or frequent changes to support.

Check this box if the client does not have emotional or mental health issues that significantly limit their self-care capacity, requiring intensive supervision and/or frequent changes to support.

Check this box if there are factors affecting the carer's availability and sustainability of the care relationship.

Check this box if there are no factors affecting the carer's availability and sustainability of the care relationship.

Check this box if the carer's emotional health and well being affect their availability and sustainability in the care relationship.

Check this box if the carer's physical health and well being affect their availability and sustainability in the care relationship.

Check this box if the carer having other responsibilities affects their availability and sustainability in the care relationship.

Check this box if the carer's work or study hours affect their availability and sustainability in the care relationship.

Check this box if other impacts of care, not listed, affect the carer's availability and sustainability in the care relationship.

Provide specific details regarding other impacts of care that affect carer availability and sustainability.

Check this box if there are factors affecting carer availability and sustainability of the care relationship.

Check this box if there are no factors affecting carer availability and sustainability of the care relationship.

Select this option if the carer's emotional health and well-being are factors affecting their availability and the sustainability of the care relationship.

Select this option if the carer's physical health and well-being are factors affecting their availability and the sustainability of the care relationship.

Select this option if the carer having other responsibilities is a factor affecting their availability and the sustainability of the care relationship.

Select this option if the carer's work or study hours are factors affecting their availability and the sustainability of the care relationship.

Select this option if other impacts of care are factors affecting the carer's availability and the sustainability of the care relationship.

Check this box if the client has experienced any falls or near falls in the last 12 months.

Check this box if the client has not experienced any falls or near falls in the last 12 months.

Enter the total number of falls or near falls that occurred in the last 12 months.

Check this box if the client has experienced any falls or near falls in the last 4 weeks.

Check this box if the client has not experienced any falls or near falls in the last 4 weeks.

Enter the total number of falls or near falls experienced by the client in the last 4 weeks.

Check this box if you get to have a yarn and spend time with family or friends all the time.

Check this box if you get to have a yarn and spend time with family or friends most of the time.

Check this box if you get to have a yarn and spend time with family or friends sometimes.

Check this box if you do not get to have a yarn and spend time with family or friends much.

Check this box if you never get to have a yarn and spend time with family or friends.

Check this box if you feel full of energy.

Check this box if you do not feel full of energy.

Check this box if you feel happy most of the time.

Check this box if you do not feel happy most of the time.

Check this box if you felt helpless over the past week.

Check this box if you did not feel helpless over the past week.

Check this box if you feel pretty worthless the way you are now.

Check this box if you do not feel pretty worthless the way you are now.

Check this box if you have not felt down, depressed, or hopeless at all in the last two weeks.

Check this box if you have felt down, depressed, or hopeless on several days in the last two weeks.

Check this box if you have felt down, depressed, or hopeless on more than half of the days in the last two weeks.

Check this box if you have felt down, depressed, or hopeless nearly every day in the last two weeks.

Check this box if you hardly ever feel listened to when talking with your family and friends.

Check this box if you feel listened to some of the time when talking with your family and friends.

Check this box if you feel listened to most of the time when talking with your family and friends.

Check this box if you have not felt nervous, anxious, or on edge at all in the last two weeks.

Check this box if you have felt nervous, anxious, or on edge on several days in the last two weeks.

Check this box if you have felt nervous, anxious, or on edge more than half of the days in the last two weeks.

Check this box if you have felt nervous, anxious, or on edge nearly every day in the last two weeks.

Check this box if the client never feels lonely, down, or socially isolated.

Check this box if the client occasionally feels lonely, down, or socially isolated.

Check this box if the client sometimes feels lonely, down, or socially isolated.

Check this box if the client feels lonely, down, or socially isolated most of the time.

Check this box if your family and friends hardly ever seem to understand you.

Check this box if your family and friends seem to understand you some of the time.

Check this box if your family and friends seem to understand you most of the time.

Check this box if you hardly ever feel useful to your family and friends.

Check this box if you feel useful to your family and friends some of the time.

Check this box if you feel useful to your family and friends most of the time.

Check this box if you are not sure whether you ever feel lonely, down, or socially isolated.

Check this box if you never feel lonely, down, or socially isolated.

Check this box if you occasionally feel lonely, down, or socially isolated.

Check this box if you sometimes feel lonely, down, or socially isolated.

Check this box if you feel lonely, down, or socially isolated most of the time.

Enter the name of the fifth health condition.

Enter a detailed description of the fifth health condition.

Enter the diagnosis status of the fifth health condition, including if it has been diagnosed and by whom.

Check this box if the fifth listed health condition is the primary health condition, having the greatest impact on the person's need for assistance with activities of daily living and social participation.

Check this box if the client themselves make or assist in making financial decisions.

Check this box if a power of attorney makes or assists the client in making financial decisions.

Check this box if an advance health directive makes or assists the client in making financial decisions.

Check this box if a person responsible or an appointed guardian makes or assists the client in making financial decisions.

Check this box if there are any financial or legal issues.

Check this box if there are no financial or legal issues.

Provide detailed information on financial or legal observations, including the names of assisting persons, the types of decisions they help with, and any existing representative relationships with the client.

Check this box if the client has enough financial resources to meet emergencies.

Check this box if the client does not have enough financial resources to meet emergencies.

Check this box if you always feel you have enough money to cover your basic needs.

Check this box if you feel you have enough money to cover your basic needs most of the time.

Check this box if you sometimes feel you have enough money to cover your basic needs.

Check this box if you do not often feel you have enough money to cover your basic needs.

Check this box if you never feel you have enough money to cover your basic needs.

Enter the type of care for the first current approval.

Enter the date when the first current approval was granted.

Enter the end date for the first current approval.

Indicate if the first current approval is an emergency approval.

Enter the name of the client's first health condition.

Provide a detailed description of the client's first health condition.

Indicate whether the client's first health condition has been diagnosed and, if so, by whom.

Check this box if the first health condition listed is the primary health condition, meaning it has the greatest impact on the person's need for assistance with activities of daily living and social participation.

Check this box if the client has any foot problems that affect their ability to walk or move about.

Check this box if the client does not have any foot problems that affect their ability to walk or move about.

Check this box if the client experiences painful feet, including painful corns or arthritis.

Check this box if the client has bunions.

Check this box if the client has gout.

Check this box if the client has swollen ankles or feet.

Check this box if the client has toe deformities such as hammer, mallet, or claw toes.

Check this box if the client has fallen arches.

Check this box if the client has other foot problems not listed and specify them in the provided text field.

Provide details of any other foot problems not listed that affect the ability to walk or move about.

Check this box if the person does not forget where they are currently located.

Check this box if the person sometimes forgets where they are currently located.

Check this box if the person always forgets where they are currently located.

Check this box if the individual does not forget the names of their family members.

Check this box if the individual sometimes forgets the names of their family members.

Check this box if the individual always forgets the names of their family members.

Check this box if the person is not forgetting things a lot, or if they rarely forget things.

Check this box if the person is sometimes forgetting a lot of things.

Check this box if the person is forgetting a lot of things all the time.

Check this box if the person does not forget what happened yesterday.

Check this box if the person sometimes forgets what happened yesterday.

Check this box if the person always forgets what happened yesterday.

Check this box if the client is currently receiving, or has been in receipt of formal or informal respite arrangements in the past 12 months.

Check this box if the client is not currently receiving, and has not been in receipt of formal or informal respite arrangements in the past 12 months.

Please provide the name of the fourth health condition.

Please describe the fourth health condition.

Please provide the diagnosis status for the fourth health condition.

Check this box if the health condition listed in the fourth row is the primary health condition, indicating it has the greatest impact on the person's need for assistance with activities of daily living and social participation.

Check this box if the client successfully recalls the 'Boomerang' image.

Check this box if the client successfully recalls the 'Emu' image.

Check this box if the client successfully recalls the 'Crocodile' image.

Check this box if the client successfully recalls the 'Boy' image.

Check this box if the client successfully recalls the 'Billy+Fire' image.

Check this box if the client successfully recalls the 'Bicycle' image.

Check this box if the client recalled 0 pictures during the free recall task.

Check this box if the client recalled 1 picture during the free recall task.

Check this box if the client recalled 2 pictures during the free recall task.

Check this box if the client recalled 3 pictures during the free recall task.

Check this box if the client recalled 4 pictures during the free recall task.

Check this box if the client recalled 5 pictures during the free recall task.

Check this box if you went to meetings of clubs, religious meetings, or other groups zero times in the past week.

Check this box if you went to meetings of clubs, religious meetings, or other groups one time in the past week.

Check this box if you went to meetings of clubs, religious meetings, or other groups two times in the past week.

Check this box if you went to meetings of clubs, religious meetings, or other groups three times in the past week.

Check this box if you went to meetings of clubs, religious meetings, or other groups four times in the past week.

Check this box if you went to meetings of clubs, religious meetings, or other groups five times in the past week.

Check this box if you went to meetings of clubs, religious meetings, or other groups six times in the past week.

Check this box if you went to meetings of clubs, religious meetings, or other groups seven or more times in the past week.

Check this box if the person spent time once during the past week with someone who does not live with them, through an in-person visit or outing.

Check this box if the person spent time twice during the past week with someone who does not live with them, through in-person visits or outings.

Check this box if the person spent time three times during the past week with someone who does not live with them, through in-person visits or outings.

Check this box if the person spent time four times during the past week with someone who does not live with them, through in-person visits or outings.

Check this box if the person spent time five times during the past week with someone who does not live with them, through in-person visits or outings.

Check this box if the person spent time six times during the past week with someone who does not live with them, through in-person visits or outings.

Check this box if the person spent time seven or more times during the past week with someone who does not live with them, through in-person visits or outings.

Check this box if you did not talk or communicate with anyone on the telephone, mobile, or social media in the past week.

Check this box if you talked or communicated with someone once on the telephone, mobile, or social media in the past week.

Check this box if you talked or communicated with someone twice on the telephone, mobile, or social media in the past week.

Check this box if you talked or communicated with someone three times on the telephone, mobile, or social media in the past week.

Check this box if you talked or communicated with someone four times on the telephone, mobile, or social media in the past week.

Check this box if you talked or communicated with someone five times on the telephone, mobile, or social media in the past week.

Check this box if you talked or communicated with someone six times on the telephone, mobile, or social media in the past week.

Check this box if you talked or communicated with someone seven or more times on the telephone, mobile, or social media in the past week.

Check this box if the client's performance on the 'Crosses and circles' copying task corresponds to option 0.

Check this box if the client's performance on the 'Crosses and circles' copying task corresponds to option 1.

Check this box if the client scores 0 for the Frontal/Executive Function task.

Check this box if the client scores 1 for the Frontal/Executive Function task.

Provide a holistic summary of the client's level of function, impact on daily living, unmet needs, required services and supports, and outcomes of relevant Supplementary Assessment Tools.

Select this option if you feel that things for your future planning, including health, care, funeral wishes, and family's well-being, are in place all the time.

Select this option if you feel that things for your future planning, including health, care, funeral wishes, and family's well-being, are in place most of the time.

Select this option if you feel that things for your future planning, including health, care, funeral wishes, and family's well-being, are in place sometimes.

Select this option if you feel that not much is in place for your future planning, including health, care, funeral wishes, and family's well-being.

Select this option if you feel that nothing is in place for your future planning, including health, care, funeral wishes, and family's well-being.

Provide any general and personal health observations regarding the client's health.

Provide any additional general health notes or comments.

Provide a detailed account of observations made regarding the client's home environment and safety.

Provide any general notes regarding wellbeing and safety.

Please provide details regarding your government pension or benefits.

Please enter the full address of the GP.

Please enter the given name of the GP.

Please enter the surname of the GP.

Please enter the email address of the GP.

Please enter the mobile phone number of the GP.

Please enter any other phone number for the GP.

Check this box if it is suitable for the client to complete GPCog - Step 1.

Check this box if it is not suitable for the client to complete GPCog - Step 1.

Check this box if an informant is available to complete GPCog – Step 2, which is detailed on page 50.

Check this box if an informant is not available to complete GPCog – Step 2.

Check this box if you are able to take care of your personal appearance, including your face, hair, teeth cleaning, and shaving, without any help.

Check this box if you require some assistance to take care of your personal appearance, including your face, hair, teeth cleaning, and shaving.

Check this box if you are completely unable to take care of your personal appearance, including your face, hair, teeth cleaning, and shaving.

Enter any additional details regarding the client's grooming capabilities and needs for personal appearance.

Check this box if informal carers provide help with grooming.

Check this box if aged care service providers help with grooming.

Check this box if help with grooming is provided by individuals or services not listed above.

Provide details about other grooming help providers not listed in the options above.

Check this box if it cannot be determined whether the client experiences hallucinations or delusions.

Check this box if the client never experiences hallucinations or delusions.

Check this box if the client occasionally experiences hallucinations or delusions.

Check this box if the client regularly experiences hallucinations or delusions.

Check this box if the client always experiences hallucinations or delusions.

Check this box if the client can handle their money without any help.

Check this box if the client needs some help to handle their money.

Check this box if the client is completely unable to handle their money.

Check this box if a person with power of attorney makes or assists in making the client's health decisions.

Check this box if an advance health directive guides the client's health decisions.

Check this box if a person responsible for the client or an appointed guardian makes or assists in making the client's health decisions.

Check this box if health issues have not affected your normal activities at all during the past 4 weeks.

Check this box if health issues have slightly affected your normal activities during the past 4 weeks.

Check this box if health issues have moderately affected your normal activities during the past 4 weeks.

Check this box if health issues have affected your normal activities quite a bit during the past 4 weeks.

Check this box if the client has poor hearing.

Check this box if the client has deafness.

Check this box if there is help available for the client's home maintenance.

Check this box if there is no help available for the client's home maintenance.

Check this box if the client's partner helps with home maintenance.

Check this box if the client's mother helps with home maintenance.

Check this box if the client's father helps with home maintenance.

Check this box if the client's daughter helps with home maintenance.

Check this box if the client's son helps with home maintenance.

Check this box if the client's daughter-in-law helps with home maintenance.

Check this box if the client's son-in-law helps with home maintenance.

Check this box if another relative helps with home maintenance.

Check this box if a friend or neighbour helps with home maintenance.

Check this box if a service provider helps with home maintenance.

Check this box if someone other than the listed options provides help with home maintenance.

Provide specific details if 'Other' was selected for who helps with the client's home maintenance.

Please provide details of the 'Other' help provider for walking assistance.

Check this box if the home and garden environment is assessed to be safe.

Check this box if there are moderate environmental hazards in the home and garden that require modification.

Check this box if there are minimal environmental hazards identified in the home and garden.

Check this box if the home and garden environment is assessed to be extremely unsafe.

Provide any notes regarding the client's home and personal safety assessment.

Check this box if the client is able to keep their home in a safe and habitable condition regarding home maintenance concerns.

Check this box if the client is not able to keep their home in a safe and habitable condition regarding home maintenance concerns.

Provide details on the client's home maintenance activities, their frequency, and any assistance or supervision received for home, garden, or yard maintenance.

Check this box if there are no risks, hazards, or safety concerns in your home, including environmental concerns.

Check this box if there are risks, hazards, or safety concerns in your home, including environmental concerns.

Check this box if you are unsure whether there are risks, hazards, or safety concerns in your home, including environmental concerns.

Check this box if the client has one or more smoke alarms installed in their home.

Check this box if the client possesses a personal alarm system.

Check this box if the client has a personal emergency plan in place.

Check this box if the client has other safety-related technology not specified in the other options.

Check this box if the client has been admitted to the hospital in the last 12 months for a planned reason.

Check this box if the client has been admitted to the hospital in the last 12 months for an unplanned reason.

Check this box if the client has not been admitted to the hospital in the last 12 months.

Provide the date of admission, reason for admission (scheduled, unplanned, or emergency department visit), information about the hospital stay, and date of discharge.

Enter the number of people, excluding the client, who reside in the same household.

Check this box if the person can undertake heavy or moderate housework without any assistance.

Check this box if the person requires some assistance to undertake heavy or moderate housework.

Check this box if the person is completely unable to undertake heavy or moderate housework.

Provide additional details on how the client is currently completing household activities, including any assistance or supervision received, who provides the support, what support is provided, and the period of time the client has received the support for.

Provide specific details if 'Other' was selected for who helps with housework.

Check this box if no one helps the client with housework.

Check this box if informal carers help the client with housework.

Check this box if aged care service providers help the client with housework.

Check this box if someone other than those listed helps the client with housework.

Check this box if the client's housework need is completely unmet.

Check this box if the client's housework need is partially met.

Check this box if the client's housework need is completely met.

Check this box if the client does not require assistance for housework.

Check this box if the client's housework need is completely unmet.

Check this box if the client's housework need is partially met.

Check this box if the client's housework need is completely met.

Check this box if the client does not require assistance for housework.

Specify the details of the other helper for housework tasks.

Check this box if health issues have had no impact at all on normal activities.

Check this box if health issues have slightly impacted normal activities.

Check this box if health issues have moderately impacted normal activities. Note that completing the 'Advanced Medical Assessment' section may be required.

Check this box if health issues have impacted normal activities quite a bit. Note that completing the 'Advanced Medical Assessment' section may be required.

Check this box if you are in good spirits most of the time.

Check this box if you are not in good spirits most of the time.

Check this box if the individual is continent (does not experience incontinence) for a period of over 7 days.

Check this box if the individual experiences an occasional bladder accident, defined as a maximum of once per 24 hours.

Check this box if the individual is incontinent, or is catheterised and unable to manage their bladder function.

Please provide the full name of the informant.

Please provide the date when the informant interview took place.

Check this box if you have had little interest or pleasure in doing things not at all over the last two weeks.

Check this box if you have had little interest or pleasure in doing things for several days over the last two weeks.

Check this box if you have had little interest or pleasure in doing things for more than half of the days over the last two weeks.

Check this box if you have had little interest or pleasure in doing things nearly every day over the last two weeks.

Check this box if the client is currently an admitted hospital inpatient.

Check this box if the client is not currently an admitted hospital inpatient.

Check this box if the client is managing their urinary incontinence issue.

Check this box if the client is not managing their urinary incontinence issue.

Check this box if the client is currently taking medications to manage their health conditions.

Check this box if the client is not currently taking any medications.

Check this box if the client's need is completely unmet.

Check this box if the client's need is partially met.

Check this box if the client's need is completely met.

Check this box if the client does not require assistance for this need.

Select this option if the identified need has not been met at all.

Select this option if the identified need has been met to some extent but not fully.

Select this option if the identified need has been fully met.

Select this option if the client does not require assistance for this particular need.

Check this box if the person gave a correct answer when identifying the comb.

Check this box if the user provides an incorrect answer when asked to identify the matches.

Check this box if the user provides a correct answer when asked to identify the matches.

Check this box if the subject gave an incorrect answer when asked to identify the pannikin (cup).

Check this box if the subject gave a correct answer when asked to identify the pannikin (cup).

Check this box if the user provides an incorrect answer regarding the use of the comb.

Check this box if the user provides a correct answer regarding the use of the comb.

Check this box if the subject provides an incorrect response when asked what matches are used for.

Check this box if the subject provides a correct response when asked what matches are used for.

Check this box if the subject incorrectly identifies or describes the use of the pannikin (cup).

Check this box if the subject correctly identifies or describes the use of the pannikin (cup).

Check this box if the user provides an incorrect answer for what the comb is used for.

Check this box if the user provides a correct answer for what the comb is used for.

Check this box if the subject gave an incorrect answer when asked about the use of matches.

Check this box if the subject gave a correct answer when asked about the use of matches.

Check this box if the subject gives an incorrect answer for what the pannikin (cup) is for.

Check this box if the subject gives a correct answer for what the pannikin (cup) is for.

Check this box if the client or their representative sought assessment due to a referral from a health professional.

Check this box if the client or their representative sought assessment due to a recent hospital discharge.

Check this box if the client or their representative sought assessment due to one or more falls.

Check this box if the client or their representative sought assessment due to an existing or new medical condition.

Check this box if the client or their representative sought assessment due to difficulties with daily activities such as bathing, dressing, or eating.

Check this box if the client or their representative sought assessment due to a change in their current caring arrangements.

Check this box if the client or their representative sought assessment due to an overall change in their care needs.

Check this box if the client or their representative sought assessment due to a change in their living situation.

Check this box if the client or their representative sought assessment due to a change in the client's cognitive abilities or mental clarity.

Check this box if the client or their representative sought assessment due to a change in the client's mental health.

Check this box if the client or their representative sought assessment because the client is experiencing social isolation or loneliness.

Check this box if the key circumstance for assessment is not covered by any of the other options provided.

Provide a detailed description of the key circumstance for assessment if 'Other' was selected.

Check this box if the client or representative is making contact due to a referral from a health professional.

Check this box if the client or representative is making contact because of a hospital discharge.

Check this box if the client or representative is making contact due to one or more falls.

Check this box if the client or representative is making contact because of one or more medical conditions.

Check this box if the client or representative is making contact due to difficulties with activities of daily living.

Check this box if the client or representative is making contact because of a change in caring arrangements.

Check this box if the client or representative is making contact due to a change in their care needs.

Check this box if the client or representative is making contact due to a change in living arrangements.

Check this box if the client or representative is making contact because of a change in cognitive status.

Check this box if the client or representative is making contact due to a change in mental health status.

Check this box if the client or representative is making contact for a reason not listed above.

Specify any other key circumstance(s) that triggered the client or representative making contact.

Check this box if an informant is available to complete the Kimberley Indigenous Cognitive Assessment - Carer.

Check this box if an informant is not available to complete the Kimberley Indigenous Cognitive Assessment - Carer.

Check this box if it is suitable for an Aboriginal and/or Torres Strait Islander client to complete the KICA COG Regional Urban assessment.

Check this box if it is not suitable for an Aboriginal and/or Torres Strait Islander client to complete the KICA COG Regional Urban assessment.

Check this box if it is suitable for the client to complete the KICA COG assessment, and proceed to KICA-COG: Cognitive Assessment on page Append_p6.

Check this box if it is not suitable for the client to complete the KICA COG assessment.

Check this box if you hardly ever know what is going on with your family and friends.

Check this box if you know what is going on with your family and friends some of the time.

Check this box if you know what is going on with your family and friends most of the time.

Check this box if bowel or stool leakage never causes the client to alter their lifestyle.

Check this box if bowel or stool leakage rarely causes the client to alter their lifestyle.

Check this box if bowel or stool leakage sometimes causes the client to alter their lifestyle.

Check this box if bowel or stool leakage often or usually causes the client to alter their lifestyle.

Check this box if bowel or stool leakage always causes the client to alter their lifestyle.

Check this box if the client never leaks stool when they don't get to the toilet in time.

Check this box if the client rarely leaks stool when they don't get to the toilet in time.

Check this box if the client sometimes leaks stool when they don't get to the toilet in time.

Check this box if the client often or usually leaks stool when they don't get to the toilet in time.

Check this box if the client always leaks stool when they don't get to the toilet in time.

Check this box if stool leakage never requires an underwear change.

Check this box if stool leakage rarely requires an underwear change.

Check this box if stool leakage sometimes requires an underwear change.

Check this box if stool leakage often or usually requires an underwear change.

Check this box if stool leakage always requires an underwear change.

Check this box if you feel that your life is empty.

Check this box if you do not feel that your life is empty.

Check this box if the client can undertake light housework tasks without any assistance.

Check this box if the client requires some assistance to undertake light housework tasks.

Check this box if the client is completely unable to undertake light housework tasks.

Please provide details about the linking supports suggested for assessment.

Check this box if the client never leaks, has accidents, or loses control with liquid stool.

Check this box if the client rarely leaks, has accidents, or loses control with liquid stool.

Check this box if the client sometimes leaks, has accidents, or loses control with liquid stool.

Check this box if the client often or usually leaks, has accidents, or loses control with liquid stool.

Check this box if the client always leaks, has accidents, or loses control with liquid stool.

Check this box if the extent of loneliness cannot be determined.

Check this box if the individual never experiences loneliness.

Check this box if the individual occasionally experiences loneliness.

Check this box if the individual regularly experiences loneliness.

Check this box if the individual always experiences loneliness.

Check this box if it is not possible to determine if the client has long term memory problems.

Check this box if the client never experiences long term memory problems.

Check this box if the client occasionally experiences long term memory problems.

Check this box if the client regularly experiences long term memory problems.

Check this box if the client always experiences long term memory problems.

Check this box if the person is unable to sit up over the edge of the bed.

Check this box if the person requires 'hands-on' physical but minimal assistance, primarily to guide movement, to sit up over the edge of the bed.

Check this box if the person requires supervision, meaning another person monitors the activity without providing hands-on assistance, to sit up over the edge of the bed.

Check this box if the person is able to sit up over the edge of the bed without the presence of another person for safe mobility.

Check this box if the main reason for seeking assistance is to improve the client's current level of function and/or independence following a recent acute illness or event.

Check this box if the main reason for seeking assistance is to improve the client's current level of function and/or independence for a reason other than a recent acute illness or event.

Check this box if the main reason for seeking assistance is to maintain the client's current level of function and/or independence.

Check this box if the main reason for seeking assistance is to reduce the rate at which the client's level of function and/or independence is declining.

Check this box if the main reason for seeking assistance is not described by any of the other options, and then provide a specific explanation in the corresponding text field.

Provide details if the main reason for seeking assistance is not listed among the options.

Check this box if the client has any major skin conditions.

Check this box if the client does not have any major skin conditions.

Check this box if the client has a pressure ulcer as a major skin condition.

Check this box if the client has an other type of skin ulcer as a major skin condition.

Check this box if the client has healing surgical wounds as a major skin condition.

Check this box if the client has other skin tears, cuts, or lesions as a major skin condition.

Check this box if the client has other skin problems such as bruising, rashes, or eczema as a major skin condition.

Check this box if the client has a major skin condition not listed above and specify it.

Provide details regarding the client's major skin conditions, including their impact on daily functioning, treatment, management, and any referral requirements for nursing or wound management.

Check this box if the person can prepare meals without any assistance.

Check this box if the person requires some assistance to prepare meals.

Check this box if the person is completely unable to prepare meals.

Provide detailed information on how the client currently completes meal preparation, including any received assistance, who provides the support, what type of support is given, and the period of time for which the support has been received.

Check this box if the client's meal preparation need is completely unmet.

Check this box if the client's meal preparation need is partially met.

Check this box if the client's meal preparation need is completely met.

Check this box if the client does not require assistance with meal preparation.

Check this box if a generalist medical practitioner participated in the client's comprehensive assessment.

Check this box if a geriatrician participated in the client's comprehensive assessment.

Check this box if a psychogeriatrician participated in the client's comprehensive assessment.

Check this box if a psychiatrist participated in the client's comprehensive assessment.

Check this box if a rehabilitation specialist participated in the client's comprehensive assessment.

Check this box if any other medical practitioners not listed above participated in the client's comprehensive assessment.

Check this box if the client is receiving drip infusion in a vein.

Check this box if the client is receiving home dialysis (peritoneal or haemodialysis).

Check this box if the client is receiving dialysis at a centre or hospital.

Check this box if the client requires stoma care.

Check this box if the client is receiving oxygen therapy.

Check this box if the client is using a ventilator.

Check this box if the client is using a nebuliser.

Check this box if the client requires tracheostomy care.

Check this box if the client is receiving nursing care specifically for pain management.

Check this box if the client is receiving an enteral feeding supplement via bolus.

Check this box if the client is receiving an enteral feeding supplement via a non-bolus method.

Check this box if the client is receiving parenteral feeding (intra-venous hyperalimentation).

Check this box if the client requires care for a chronic ulcer.

Check this box if the client has a urethral catheter.

Check this box if no one helps the client with taking medicine or administering injections.

Check this box if informal carers, such as family, friends, or neighbours, help the client with taking medicine or administering injections.

Check this box if an Aged Care Service Provider helps the client with taking medicine or administering injections.

Check this box if someone other than the listed options helps the client with taking medicine or administering injections.

Provide specific details about who helps with medicine if 'Other' was selected.

Check this box if you are not sure whether you experience memory loss or confusion.

Check this box if you do not experience memory loss or confusion at all.

Check this box if you occasionally experience memory loss or confusion.

Check this box if you sometimes experience memory loss or confusion.

Check this box if you experience memory loss or confusion most of the time.

Check this box if the client has a memory problem or confusion that significantly limits self-care capacity, requiring intensive supervision and/or frequent changes to support.

Check this box if the client does not have a memory problem or confusion that significantly limits self-care capacity, requiring intensive supervision and/or frequent changes to support.

Check this box if the client is subject to a Mental Health Act order.

Check this box if the client is not subject to a Mental Health Act order.

Provide specific details regarding the Mental Health Act order if the client is subject to one.

Check this box if the assessment was conducted face-to-face.

Check this box if the assessment was conducted over-the-phone.

Check this box if the assessment was conducted via tele-health, including options such as video conferencing.

Check this box if the user's answer to the 'What month is it?' question is incorrect.

Check this box if the user's answer to the 'What month is it?' question is correct.

Check this box if you feel you have more problems with memory than most.

Check this box if you do not feel you have more problems with memory than most.

Please enter the name of the person.

Check this box if the number '42' was recalled correctly as part of the name and address recall.

Check this box if the number '42' was recalled incorrectly as part of the name and address recall.

Check this box if the name 'Brown' was recalled correctly.

Check this box if the name 'Brown' was recalled incorrectly.

Check this box if the name and address associated with John were recalled correctly.

Check this box if the name and address associated with John were recalled incorrectly.

Check this box if 'Kensington' was correctly remembered.

Check this box if 'Kensington' was incorrectly remembered.

Check this box if 'West Street' was correctly recalled.

Check this box if 'West Street' was incorrectly recalled.

Please enter the full name of the person the client is caring for.

Check this box if the patient requires more assistance with transport, including both private and public options.

Check this box if the patient does not require more assistance with transport, or if their difficulties are exclusively due to physical problems such as a bad leg.

Check this box if it is uncertain whether the patient requires more assistance with transport.

Check this box if the question about the patient's need for transport assistance is not relevant or cannot be answered.

Check this box if the need is completely unmet.

Check this box if the need is partially met.

Check this box if the need is completely met.

Check this box if the client does not require assistance for the need.

Check this box if the client's need is entirely not being met.

Check this box if the client's need is being met to some extent but not fully.

Check this box if the client's need is entirely being met.

Check this box if the client does not need any assistance for this activity.

Enter the ninth health condition.

Provide a detailed description of the ninth health condition.

Enter the diagnosis status of the ninth health condition.

Check this box if the ninth listed health condition has the greatest impact on the person's need for assistance with activities of daily living and social participation.

Check this box if NRS is required.

Check this box if NRS is not required.

Check this box if you feel you can depend on or feel very close to no persons in your local area, other than family members.

Check this box if you feel you can depend on or feel very close to 1 to 2 persons in your local area, other than family members.

Check this box if you feel you can depend on or feel very close to more than 2 persons in your local area, other than family members.

Check this box if the client currently takes between 0 and 4 types of medications, including over-the-counter medicines.

Check this box if the client currently takes between 5 and 14 types of medications, including over-the-counter medicines.

Check this box if the client currently takes 15 or more types of medications, including over-the-counter medicines.

Check this box if the person recalled 0 of the objects shown during the object recall assessment.

Check this box if the person recalled 1 of the objects shown during the object recall assessment.

Check this box if the person recalled 2 of the objects shown during the object recall assessment.

Check this box if the person recalled 3 of the objects shown during the object recall assessment.

Check this box if you often get bored.

Check this box if you do not often get bored.

Check this box if the client is able to use online services without any help.

Check this box if the client is able to use online services with some help.

Check this box if the client is completely unable to use online services.

Check this box if no one helps the client with online services.

Check this box if an informal carer or carers help the client with online services.

Check this box if an aged care service provider or providers help the client with online services.

Check this box if someone other than the listed options helps the client with online services.

Enter the specific details of who helps the client with online services if 'Other' was selected.

Check this box if the client's need for online services is completely unmet.

Check this box if the client's need for online services is partially met.

Check this box if the client's need for online services is completely met.

Check this box if the client does not require any assistance with online services.

Provide any additional details about the client's online service needs, specifically regarding their ability to access internet sites, make online payments, and navigate websites.

Check this box if the client has any oral health concerns, such as problems with their teeth, mouth, or dentures.

Check this box if the client does not have any oral health concerns, such as problems with their teeth, mouth, or dentures.

Provide specific details about any oral health concerns the client has, such as issues with their oral health, teeth, mouth, dentures, pain while eating, or recent dental practitioner visits.

Provide details about who helps the client use other communication devices, if 'Other' was selected.

Provide specific details about who else provides help, if 'Other' was selected as a helper category.

Provide specific details regarding other impacts of care that affect the carer's availability and sustainability of the care relationship.

Specify the 'Other' helper who assists with meal preparation.

Please specify the other relationship not listed to the person the client is caring for.

Provide details for the 'Other' telephone helper, explaining who helps and how.

Provide detailed notes regarding the outcome or advice for the assessment, limited to 500 characters.

Enter any notes or comments from the assessor.

Enter general observations about the client's abilities, energy levels, stamina, comprehension, memory, concentration, physical appearance, interpersonal behaviour, and engagement in the assessment.

Check this box if the client has health literacy difficulties.

Check this box if the client does not have health literacy difficulties.

Provide details on the client's health literacy difficulties, including their impact on understanding health information and any required support.

Provide detailed observations regarding frailty.

Provide information regarding the client's personal and family support networks, including their family situation, engagement with social groups, recent changes in their social situation, and any experience of loneliness or social isolation.

Provide a detailed description of the psychological conditions, signs, and symptoms identified at assessment, including how they affect a client's ability to undertake activities of daily living and instrumental activities of daily living, and any recorded outcomes of relevant Supplementary Assessment Tools.

Check this box if the person helping the client has paid employment on a full-time basis.

Check this box if the person helping the client has paid employment on a part-time basis.

Check this box if the person helping the client does not have any paid employment.

Check this box if the client has often experienced pain during the past month that made it difficult to perform daily activities.

Check this box if the client has not often experienced pain during the past month that made it difficult to perform daily activities.

Provide details regarding the pain experienced during daily activities, including the cause, level, location, impact on functional activities or sleep, and strategies used to manage the pain.

Check this box if pain has not often been too painful to do many daily activities in the past month.

Check this box if pain has often been too painful to do many daily activities in the past month.

Check this box if you are unsure whether pain has often been too painful to do many daily activities in the past month.

Check this box if participants were consulted prior to the assessment.

Check this box if no participants were consulted prior to the assessment.

Check this box if the participant's answer to the question 'Is this pension/pay week?' or 'What month is it?' is incorrect.

Check this box if the participant's answer to the question 'Is this pension/pay week?' or 'What month is it?' is correct.