Current Observations / System Review Initial Date □ □ Details: Pain□ No Yes □ □ Details: Dizziness□ No Yes □ □ Details: Short breath on exertion/rest□ No Yes □ □ Visual impairment□ No Yes Details : refer to OT – □ □ □ Glasses□ No Yes Eyes tested in last 2yrs□□□ No Yes □ □ No Yes Hearing impairment□ Details: hearing – □ □ Smoking□ Never Quit date: / /____ Consumption: □ aids? No □ □ Alcohol□ Never Quit date: / / Consumption: type: □ Yes □ □ Sleep/rest pattern Problem falling asleep Yes No □ □ Problem staying asleep Yes No □ □ Sleeping tablets taken? Yes No If please specify below: ‘yes’ Type: How often: Comments Medication Initial Date □ □ □ Administration□ Self Supervised Assistance, please specify: □ □ Concern expressed about compliance No Yes □ □ □ □ Aids/support used□ Webster/blister pack Dosette Box Boxes/bottles Timer □ □ No Yes 5 or more medications□ □ □ Difficulties swallowing medication□ No Yes    If any concern, action taken: Advised visit GP OT referral SW referral discuss in team meeting Communication & Swallowing Initial Date □ □ Do you have any difficulties swallowing food, fluids or medications? e.g. coughing, choking. Yes No □ □ Have you noticed any changes to your speech/voice? Yes No e.g. less clear, more effortful, difficulty thinking of or saying words. Are you having difficulty understanding language or writing? □ □ Yes No e.g. difficulty making sense of a sentence, conversation or written information.   If any concern please refer to Speech Pathologist Referral completed? Yes No Mobility Initial Date □ □ □ Transfers Independent Requires assistance Aids: □ □ Indoor ambulation□ Independent Requires assistance Aids: □ □ Outdoor ambulation□ Independent Requires assistance Aids: □ □ Stairs□ Independent Requires assistance Aids:   If any concern please refer to Physio Referral completed? Yes No
Current Observations / System Review Initial Date Pain□ □ No □ Yes Details: Dizziness□ □ No □ Yes Details: Short breath on exertion/rest□ □ No □ Yes Details: Visual impairment□ □ No □ Yes – refer to OT Details : Glasses□ □ No □ Yes Eyes tested in last 2yrs□□□ No □ Yes Hearing impairment□ □ No □ Yes – hearing aids? □ No □ Yes Details: Smoking□ □ Never □ Quit date: / /____ Consumption: Alcohol□ □ Never □ Quit date: / / Consumption: type: Sleep/rest pattern Problem falling asleep □ Yes □ No Problem staying asleep □ Yes □ No Sleeping tablets taken? □ Yes □ No If ‘yes’ please specify below: Type: How often: Comments Medication Initial Date Administration□ □ Self □ Supervised □ Assistance, please specify: Concern expressed about compliance □ No □ Yes Aids/support used□ □ Webster/blister pack □ Dosette Box □ Boxes/bottles □ Timer 5 or more medications□ □ No □ Yes Difficulties swallowing medication□ □ No □ Yes If any concern, action taken: Advised visit GP OT referral  SW referral  discuss in team meeting  Communication & Swallowing Initial Date Do you have any difficulties swallowing food, fluids or medications? e.g. coughing, choking. □ Yes □ No Have you noticed any changes to your speech/voice? e.g. less clear, more effortful, difficulty thinking of or saying words. □ Yes □ No Are you having difficulty understanding language or writing? e.g. difficulty making sense of a sentence, conversation or written information. □ Yes □ No If any concern please refer to Speech Pathologist Referral completed?  Yes  No Mobility Initial Date Transfers □ □ Independent □ Requires assistance Aids: Indoor ambulation□ □ Independent □ Requires assistance Aids: Outdoor ambulation□ □ Independent □ Requires assistance Aids: Stairs□ □ Independent □ Requires assistance Aids: If any concern please refer to Physio Referral completed?  Yes  No
WA_DTU_Interdisciplinary_Screen_Form.docx