M5 Programs

Name of Person filling out this form

Participants First Name

Participants Last Name

Email Address

Phone Number

Representative Full Name and contact

Relationship to Participant

Indigenous Status Indigenous Status Aboriginal but not Torres Straight Islander origin Torres Straight Islander but not Aboriginal origin Both Aboriginal and Torres Straight Islander origin Neither Aboriginal nor Torres Straight Islander origin

Cultural / religious affiliation? If so, please specify:

Medicare Number

Do you take any medications? If so please list them, the dosage and times they are taken.

Do you require assistance with Medication? Do you require assistance with Medication? Yes No

If so, can you detail the Medication assistance needed:

Do you need Prompting for medication Do you need Prompting for medication Yes No

What medication do you need assistance with?

Do you have any allergies? (please include Food, Medication or other) or indicate 'no' if no allergies

Are there any tasks of daily living or self-care tasks that you need assistance with? If so, please list.

Do you have an asthma plan, epilepsy plan, anaphylaxis plan etc? Do you have an asthma plan, epilepsy plan, anaphylaxis plan etc? Yes No

Do you have a Companion Card? Do you have a Companion Card? Yes No

Do you have any access or parking issues when support staff come to visit you in your home? Do you have any access or parking issues when support staff come to visit you in your home? Park on Street Park in Driveway Access through the Front Door Access through the back door Beware of the Dog Don't let the cat out Other

Is there any information we need to know about transporting you? Is there any information we need to know about transporting you? Pick up required Drop off required Will be using Uber I have a disability permit Will be dropped off by a family member/friend I will be picked up by a family member/friend Other

We would love to know more about you! Can you give us some information about your history, culture, family and friends?

Do you have any pets you would like to tell us about?

Do you have an Emergency Pendant? (If so, Please provide details)

Is there anything you would like us to know about if there was ever an emergency Is there anything you would like us to know about if there was ever an emergency Need assistance exiting building - has Mobility issues Have a backpack of essential items Anxiety in emergencies Have mobility and other equipment Need to contact emergency contact immediately Other

What supports do you rely on every day that are critical for your health and safety? (e.g., medication, personal care, feeding equipment).

What would you like us to do if no-one is at home if we are dropping you off?

Do you have any health conditions we need to know about?

Are you a Smoker Are you a Smoker Yes No Prefer not to answer

Are you a falls risk? Are you a falls risk? Yes No

Do you have any behaviours or reactions we should be aware of so we can support you in the best way possible?”

Do you have any equipment we should know about? Do you have any equipment we should know about? Emergency Pendant or Watch Hearing aids Fall detection alarms GPS Tracker Other

What are your NDIS Goals?

Do you have any personal goals you would like us to help you achieve?

What are your likes? What things are important for people to understand about you when caring for you?

What are your dislikes?

Do you have any Mobility Issues we need to be aware of? (i.e. issues with walking, in a wheelchair etc)

Any issues with incontinence? Any issues with incontinence? Yes No Prefer not to answer

How do you find communicating with others? How do you find communicating with others? No Issues communicating Mild Issues with communicating Moderate Issues with communicating Significant Issues with communicating

Do you have issues with hearing? Do you have issues with hearing? No hearing issues Mild difficulty hearing Moderate difficulty hearing Significant hearing issues

Do you have issues with your vision/seeing? Do you have issues with your vision/seeing? No vision issues Mild vision issues Moderate vision issues Significant vision issues

Do you need assistance with understanding information and need to be spoken to in simpler wording? Do you need assistance with understanding information and need to be spoken to in simpler wording? Yes No

Can you tell us if you have a Mealtime Plan that needs to be prepared and details of this?

Do you have any difficulty swallowing food? Do you have any difficulty swallowing food? Yes No

Hospital preference

Pharmacist Details

Specialist Details (please include name, practice, address & phone)

Other Allied Health Contacts (please include name, practice, address & phone)

Vaccination details (e.g. up-to-date)

Regular medical and dental check ups and History (e.g. Up-to-date

Is there anything extra you would like to let us know?

Tick this box and write your name to acknowledge that you are submitting this information Tick this box and write your name to acknowledge that you are submitting this information I acknowledge that this organisation has provided me with information regarding policies and procedures relevant to my support plan. I am fully aware of my rights and responsibilities during my affiliation with this organisation. By typing my name below I confirm that the information entered into this form is correct to my best knowledge.

Write your name here for confirmation of the statement above