client self assessment

Stick a photo of
yourself here
My Needs
Assessment
This assessment was assisted by the following staff; (Signature & P.I.N.)
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
I was able to participate in my assessment; Yes □ No □
If no please provide some explanation below (Staff)
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………

Nursing Assessment Framework
To best capture and promote individual uniqueness St Joseph’s
Intellectual Disability Service uses the Roper, Logan and Tierney’s
Activities of Living Nursing Model combined with the Orem’s Self Care
Nursing Model. This combination of evidence based frameworks
incorporates key aspects of an individual’s life to promote best practice
and a more person centred approach to the person’s needs.
This assessment has also been informed by
The OK Health Check list
The Individual’s Risk Assessments
Once completed it will in turn inform the completion of a Hospital
Passport, which will accompany the person to any external hospital.
The Aims of the Assessment
To engage with the person in helping them to promote their needs
To provide staff with information to highlight strengths and needs, to
promote choice and independence or to identify resources required to
enhance the quality of life of the person they care for
To promote a consistent approach by the care team when supporting
the person’s needs and decisions when creating a plan of care

My height and weight:
My date of birth:
My next of kin:
Name and how to contact them.
Any allergies I have:
My weight
date weighed
Your height and date measured::
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Page 5
Section 1
This Assessment has 3 Sections
Some background information page 4 and
5 This is some information that is important to
me, and helps to
Today……………..
My Height………
My Weigh….….
Section 2
My Self Assessment– pages 6 and 7
This is where you tell us what level of
support you require and in what areas
I’m all good here, I do
not need your help
I could do with some
assistance or advice
I need your help
Section 3
Important information about me
My Nursing Assessment- pages 8 to 26.
This is where we describe the supports you require
in greater detail, and summarize your goals
It is important to keep this document up to date.
You can make changes or ask staff to make changes whenever you need to

Section 1
My Name and Address
Contains private
and confidential
Information.
Date first written:
Dates when updated:

Health History
Current Diagnoses
Intellectual Disability __________________
Mental Illness________________________
Physical Illness : Refer to OK Health Check_
Immunisations
Name of Drug________________________
Date Given ________________________
Name of Drug________________________
Date Given ________________________
Name of Drug________________________
Date Given ________________________
Known Drug Allergies
I am allergic to________________________
I am allergic to _______________________
Known Food /Product Allergies
I am allergic to _______________________
I am allergic to _______________________
Refer to my current Medication Kardex

Section 2
• I’m all good here, I do
not need your help
• I could do with some
assistance or advice
• I need your help
Please colour the to indicate the level of support you
would like or need in the following areas.
Personal Grooming
Eating & Drinking
Communication
Toileting
Mobility

Breathing
Sleeping
Maintaining Personal Safety
Work
Leisure
Sexuality & Relationships
Mood
Medication
Anything you would like to add

Section3
1 Maintaining Safety Name …………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

2 Communication Name …………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

3 Breathing and Circulation Name ……………………………….
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

4 Eating, Drinking & Nutrition Name ……………………………..
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

5 Personal Hygiene, Dressing Name ………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

6 Elimination Name ………………………………………….
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

7 Mobilisation Name ………………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

8 Leisure and Social Name …………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

9 Sleep Name …………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

10 Pain Name …………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

11 Behaviour Name …………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

12 Mood / Emotions Name …………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

13 Thoughts /Perceptions Name …………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

14 Self Concepts/ Independence Name
……………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

15 Motivation Name …………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

16 Expressing Sexuality Name ………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

17 Dying and Bereavement Name …………………………...
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

15 Motivation Name …………………………………
Personal
When discussing personal safety, consider and discuss aspects of life such as
Personal safety and self harm, cognitive impairment (carelessness), substance
use/misuse.
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally Independent
□
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….
Environmental
When discussing environmental safety, consider and discuss aspects of life such
as
Kitchen use and/or cooking, Road and traffic awareness, Cognitive impairment
(carelessness),
Assistance & Supports required
Partial □ Full □ Support/Education only required □ Totally
Independent □
Nursing Care Plan required; Yes □ No □ ……………………………………………………………
Referral required to; Yes □ No □ ……………………………………………………………………..
Risk Assessment required; Yes □ No ………………………………………………………………….

My Goals
My Priority Goals for the next
three months are in the following
Areas
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Please carry these goals forward into my care
plan which will be reviewed on -----/------/--------