client self assessment

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9 Sleep Name ………………………………… Personal When discussing personal safety, consider and discuss aspects of life such as Personal safety and <strong>self</strong> 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 <strong>self</strong> 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 ………………………………………………………………….
Page 1 and 2: Stick a photo of yourself here My N
Page 3 and 4: My height and weight: My date of bi
Page 5 and 6: Health History Current Diagnoses In
Page 7 and 8: Breathing Sleeping Maintaining Pers
Page 9 and 10: 2 Communication Name …………
Page 11 and 12: 4 Eating, Drinking & Nutrition Name
Page 13 and 14: 6 Elimination Name ……………
Page 15: 8 Leisure and Social Name ………
Page 19 and 20: 12 Mood / Emotions Name ………
Page 21 and 22: 14 Self Concepts/ Independence Name
Page 23 and 24: 16 Expressing Sexuality Name ……
Page 25 and 26: 15 Motivation Name ……………

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