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