Medical Report for Carer Payment and/or Carer Allowance Instructions
This form contains 195 fields organized into 47 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Care Provision Details | ||
| No | Checkbox |
Check this box if you do not personally provide care for your partner on a daily basis because of their disability or medical condition.
|
| Care Start Day | Text |
Enter the day care started due to the disability or medical condition. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if you personally provide care for your partner on a daily basis because of their disability or medical condition.
|
| Additional Care Details | Text |
Provide any additional details regarding the care provided for your partner's disability or medical condition. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Care Start Month | Text |
Enter the month care started due to the disability or medical condition. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Care Start Year | Text |
Enter the year care started due to the disability or medical condition. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Care you provide | ||
| Care Provided Details | Text |
Please provide details about the care you offer to your partner while they are in hospital, including your involvement in their rehabilitation or treatment. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Damage Property Frequency | ||
| Often damage property | 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 damage property | 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 damage property | 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 Month | Date |
Enter the month your partner was hospitalised. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Hospitalisation Day | Date |
Enter the day your partner was hospitalised. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Hospitalisation Year | Date |
Enter the year your partner was hospitalised. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Difficulty Hearing Others | ||
| Never | Checkbox |
Check this box if your partner never has difficulty hearing others. 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 with 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 with hearing aids. 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 has difficulty hearing others, even with 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 | ||
| checkbox_e0uDx4_c4bd | CheckBox | |
| checkbox_9Uq1dn_28e2 | CheckBox | |
| checkbox_Nubk2v_7e19 | CheckBox | |
| checkbox_rJpEYt_afb6 | CheckBox | |
| Do you provide care for your partner while they are in hospital? | ||
| 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
|
| Does your partner stay overnight or longer 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. Fill only if 'Do you personally provide care for your partner on a daily basis because of the disability/medical condition?' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if your partner does stay overnight or longer with another person or organisation on a regular basis. Fill only if 'Do you personally provide care for your partner on a daily basis because of the disability/medical condition?' is 'Yes'.
Depends on:
Yes
|
| Expected release date | ||
| Day | Date |
Enter the day of your partner's expected release date from the hospital. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Month | Date |
Enter the month of your partner's expected release date from the hospital. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Year | Date |
Enter the year of your partner's expected release date from the hospital. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Fall Over Indoors Or Outdoors | ||
| 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
|
| 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
|
| 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
|
| General | ||
| text_af59_768b | Text | |
| text_d764_4df4 | Text | |
| text_6cbb_37cc | Text | |
| text_d406_51ed | Text | |
| text_2622_a522 | Text | |
| text_WxCXHm_8bf4 | Text | |
| text_H1sXL4_dce0 | Text | |
| text_ohX2bn_d214 | Text | |
| Is your partner currently in hospital? | ||
| No | Checkbox |
Check this box if your partner is not currently in hospital. Fill only if 'Do you personally provide care for your partner on a daily basis because of the disability/medical condition?' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if your partner is currently in hospital. Fill only if 'Do you personally provide care for your partner on a daily basis because of the disability/medical condition?' is 'Yes'.
Depends on:
Yes
|
| Is your partner terminally ill? | ||
| No | Checkbox |
Check this box if your partner is not terminally ill or is expected to live for more than 3 months. Fill only if 'Do you personally provide care for your partner on a daily basis because of the disability/medical condition?' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if your partner is terminally ill and is expected to live for 3 months or less. Fill only if 'Do you personally provide care for your partner on a daily basis because of the disability/medical condition?' is 'Yes'.
Depends on:
Yes
|
| Know where they are? | ||
| 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
|
| 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
|
| 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
|
| 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
|
| Know whether it is morning, afternoon or night? | ||
| 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
|
| 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
|
| 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
|
| 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
|
| Laugh/Cry Without Reason Frequency | ||
| Never | Checkbox |
Select this option 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
|
| Often | Checkbox |
Select this option 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
|
| Sometimes | Checkbox |
Select this option 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
|
| Let others know how they feel and what they want? | ||
| Sometimes | Checkbox |
Check this box if your partner sometimes lets 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 | Checkbox |
Check this box if your partner usually lets 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 | Checkbox |
Check this box if your partner always lets 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
|
| Never | Checkbox |
Check this box if your partner never lets 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
|
| Loss Of Bladder And/Or Bowel Control | ||
| Always | Checkbox |
Check this box if your partner always experiences loss of bladder and/or bowel control. 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 experiences loss of bladder and/or bowel control. 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 experiences loss of bladder and/or bowel control. 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 experiences loss of bladder and/or bowel control. 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 | ||
| Without help | Checkbox |
Check this box if your partner can move around the house independently, potentially using aids like a walking stick, frame, or wheelchair but without human 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
|
| Is confined to bed | Checkbox |
Check this box if your partner is unable to move around the house 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
|
| Move To And From Bed, Chairs, Wheelchair And Walking Aids | ||
| Without help | Checkbox |
Check this box if the person moves to and from bed, chairs, wheelchair, and walking aids 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
|
| Cannot do this | Checkbox |
Check this box if the person is unable 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
|
| With a lot of help | Checkbox |
Check this box if the person requires a significant amount of 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
|
| 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
|
| Need Help Or Attention During The Night | ||
| Never | Checkbox |
Check this box if your partner 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 your partner 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 your partner 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 your partner 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
|
| Overnight Stay: Education/Training Details | ||
| Education/training | Checkbox |
Check this box if your partner stays overnight for education or training, for example, by spending nights at a training centre or hostel. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Education/Training Number of Nights | Text |
Please enter the number of nights your partner spends at a training centre or hostel. Fill only if 'Education/training' is 'Yes'.
Depends on:
Education/training
|
| Education/Training Start Month | Text |
Please enter the month when your partner's education or training overnight stay started. Fill only if 'Education/training' is 'Yes'.
Depends on:
Education/training
|
| Education/Training Start Day | Text |
Please enter the day when your partner's education or training overnight stay started. Fill only if 'Education/training' is 'Yes'.
Depends on:
Education/training
|
| Education/Training Start Year | Number |
Please enter the year when your partner's education or training overnight stay started. Fill only if 'Education/training' is 'Yes'.
Depends on:
Education/training
|
| Overnight Stay: Other Care Details | ||
| Other care | Checkbox |
Check this box if your partner stays overnight for temporary care, with another person not living with you, or for respite care. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Number of Nights | Text |
Enter the number of nights your partner stays overnight for 'Other care'. Fill only if 'Other care' is 'Yes'.
Depends on:
Other care
|
| Start Date - Day | Text |
Enter the day (DD) when this 'Other care' arrangement started. Fill only if 'Other care' is 'Yes'.
Depends on:
Other care
|
| Start Date - Month | Text |
Enter the month (MM) when this 'Other care' arrangement started. Fill only if 'Other care' is 'Yes'.
Depends on:
Other care
|
| Start Date - Year | Text |
Enter the year (YYYY) when this 'Other care' arrangement started. Fill only if 'Other care' is 'Yes'.
Depends on:
Other care
|
| Overnight Stay: Shared Care Details | ||
| Shared care | Checkbox |
Check this box if your partner stays overnight or longer with another family member or similar shared care arrangement. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Shared Care Nights | Number |
Enter the total number of nights your partner spends in shared care. Fill only if 'Shared care' is 'Yes'.
Depends on:
Shared care
|
| Shared Care Start Date Day | Date |
Enter the day for when the shared care arrangement started. Fill only if 'Shared care' is 'Yes'.
Depends on:
Shared care
|
| Shared Care Start Date Month | Date |
Enter the month for when the shared care arrangement started. Fill only if 'Shared care' is 'Yes'.
Depends on:
Shared care
|
| Shared Care Start Date Year | Date |
Enter the year for when the shared care arrangement started. Fill only if 'Shared care' is 'Yes'.
Depends on:
Shared care
|
| Overnight Stay: Treatment Details | ||
| Treatment (other than hospitalisation) | Checkbox |
Check this box if your partner stays overnight or longer with another person or organization on a regular basis for treatment (other than hospitalisation), such as spending nights at therapy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Number of Nights | Text |
Enter the number of nights your partner stays overnight for treatment. Fill only if 'Treatment (other than hospitalisation)' is 'Yes'.
Depends on:
Treatment (other than hospitalisation)
|
| Start Day | Text |
Enter the day the overnight stays for treatment started. Fill only if 'Treatment (other than hospitalisation)' is 'Yes'.
Depends on:
Treatment (other than hospitalisation)
|
| Start Month | Text |
Enter the month the overnight stays for treatment started. Fill only if 'Treatment (other than hospitalisation)' is 'Yes'.
Depends on:
Treatment (other than hospitalisation)
|
| Start Year | Text |
Enter the year the overnight stays for treatment started. Fill only if 'Treatment (other than hospitalisation)' is 'Yes'.
Depends on:
Treatment (other than hospitalisation)
|
| Page 7 | ||
| Signature | Text |
Provide your signature to acknowledge the statement.
|
| Date Day | Text |
Enter the day of the date you are signing.
|
| Date Month | Text |
Enter the month of the date you are signing.
|
| Date Year | Number |
Enter the year of the date you are signing.
|
| Partner Dressing Ability | ||
| Cannot do this | Checkbox |
Check this box if your partner is unable to dress themselves at all. 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 your partner needs a lot of help 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 some help | Checkbox |
Check this box if your partner needs some help 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
|
| Without help | Checkbox |
Check this box if your partner 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
|
| Partner Food Consumption | ||
| Without help | Checkbox |
Check this box if your partner 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
|
| With some help | Checkbox |
Check this box if your partner 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
|
| Cannot feed themselves | Checkbox |
Check this box if your partner 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 your partner 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
|
| Partner Grooming Ability | ||
| Cannot do this | Checkbox |
Check this box if your partner is unable to look after their grooming. 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 your partner requires a lot of help to look after their grooming. 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 your partner needs some help to look after their grooming. 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 look after their grooming 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
|
| Partner Medication Management | ||
| Does not take medication | Checkbox |
Check this box if your 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 your partner is unable 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 your partner requires a lot of help to take 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 some help | Checkbox |
Check this box if your partner takes care of their own medication with some assistance. 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 takes care of their own medication 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
|
| Partner Shower/Bath Ability | ||
| Cannot do this | Checkbox |
Check this box if your partner is unable to shower or bath 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 your partner needs a lot of assistance to shower or bath themselves. 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 your partner can shower or bath themselves with some assistance. 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 shower or bath themselves 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
|
| Partner Toilet Use | ||
| Without help | Checkbox |
Check this box if your partner uses the toilet without needing any help. 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 your partner uses the toilet but requires some assistance. 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 your partner uses the toilet but requires a significant amount of assistance. 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 your partner is unable to use the toilet at all. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Partner Treatment Management | ||
| With a lot of help | Checkbox |
Check this box if your partner requires a lot of assistance to manage 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
|
| With some help | Checkbox |
Check this box if your partner requires some assistance to manage 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
|
| checkbox_2spu2y_aa5c | CheckBox | |
| Does not have treatment | Checkbox |
Check this box if your partner does not currently have any treatment to manage. 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 your partner is completely unable to manage 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
|
| Partner's Medical Conditions | ||
| Partner's Main Medical Conditions | Text |
Please list your partner's main disability or medical condition(s) for which they require care.
|
| Physical Harm Frequency | ||
| 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
|
| Remember things that happened today? | ||
| Never remembers things that happened today | 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
|
| Sometimes remembers things that happened today | 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
|
| Usually remembers things that happened today | 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
|
| Always remembers things that happened today | Checkbox |
Check this box if your partner always 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
|
| Self-Harm Frequency | ||
| Often | Checkbox |
Check this box if the person described often deliberately harms themselves. 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 described sometimes deliberately harms themselves. 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 person described never deliberately harms themselves. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Shout/Scream/Threaten Frequency | ||
| 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
|
| 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
|
| 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
|
| Understand what other people say? | ||
| 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
|
| Understand what you, the carer, say? | ||
| Always | 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
|
| Usually | 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
|
| Sometimes | 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
|
| Never | 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
|
| Unusual/Repetitive Behaviours Frequency | ||
| Often | Checkbox |
Check this box if your 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 your 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 your 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
|
| Use Continence Aids Or Equipment | ||
| With a lot of help | Checkbox |
Check this box if the partner uses continence aids or equipment (e.g., colostomy, catheter, pads) and requires a lot of physical assistance, guidance, or supervision. 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 uses continence aids or equipment (e.g., colostomy, catheter, pads) and requires some physical assistance, guidance, or supervision. 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 uses continence aids or equipment (e.g., colostomy, catheter, pads) without needing any physical assistance, guidance, or supervision. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Does not use aids | Checkbox |
Check this box if the partner does not use any continence aids or equipment. Fill only if 'Is your partner terminally ill and expected to live for 3 months or less?' is 'No'.
Depends on:
No
|
| Wander Away Frequency | ||
| 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
|
| Will your partner return to your care on their release from hospital? | ||
| 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
|
| Withdrawal/Depression Frequency | ||
| 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
|
| 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
|
| 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
|
| Your Details | ||
| Other Title | Text |
Please specify your title if it is not listed among the provided options.
|
| Title: Mr | Checkbox |
Check this box if your title is Mr.
|
| Title: Mrs | Checkbox |
Check this box if your title is Mrs.
|
| Title: Miss | Checkbox |
Check this box if your title is Miss.
|
| Title: Ms | Checkbox |
Check this box if your title is Ms.
|
| Title: Dr | Checkbox |
Check this box if your title is Dr.
|
| Family Name | Text |
Enter your family name or surname as it appears on official documents.
|
| First Given Name | Text |
Enter your first or primary given name.
|
| Other Given Names | Text |
Enter any other given names, such as middle names.
|
| Date of Birth | Date |
Provide your date of birth.
|
| Gender: Male | Checkbox |
Check this box if your gender is male.
|
| Gender: Female | Checkbox |
Check this box if your gender is female.
|
| Gender: Other | Checkbox |
Check this box if your gender is not male or female.
|
| Phone Number | Text |
Enter the main part of your contact phone number.
|
| Phone Area Code | Text |
Enter the area code part of your contact phone number.
|
| Your Partner's Details | ||
| Partner's Other Title | Text |
Please specify your partner's title if it is not listed.
|
| Mr | Checkbox |
Check this box if your partner's title is Mr.
|
| Mrs | Checkbox |
Check this box if your partner's title is Mrs.
|
| Miss | Checkbox |
Check this box if your partner's title is Miss.
|
| Ms | Checkbox |
Check this box if your partner's title is Ms.
|
| Dr | Checkbox |
Check this box if your partner's title is Dr.
|
| Partner's Family Name | Text |
Please enter your partner's family name.
|
| Partner's First Given Name | Text |
Please enter your partner's first given name.
|
| Partner's Other Given Name(s) | Text |
Please enter any other given names your partner may have.
|
| Partner's Date of Birth Day | Text |
Please enter the day of your partner's birth.
|
| Partner's Date of Birth Year | Text |
Please enter the year of your partner's birth.
|
| Male | Checkbox |
Check this box if your partner's sex is Male.
|
| Female | Checkbox |
Check this box if your partner's sex is Female.
|
| Other | Checkbox |
Check this box if your partner's sex is Other.
|
| Partner's Date of Birth Month | Text |
Please enter the month of your partner's birth.
|