Full Name of NDIS Participant

Gender

• Male

• Female

NDIS DIAGNOSIS

Mobility

• Good to Fair- Good to fair mobility (e.g. I am able to get up, into the bathroom and start my day without the use of aids; If I needed to, I could walk a short distance to the local shops for groceries)

• Use aids to support themselves, occasional wheelchair use.

• High risk of falling, multiple falls in the last 6 months, wheelchair bound, seizures and tremors.

Further details

Independence in daily life

Further details

Experiences fatigue

Further details

Experiences anxiety in public spaces and with new people

Triggers- Psychosocial & Environmental

• Low

• Med

• High

Help with preparing food/meals

Personal Care Requirements

• None

• Support with showering & dressing

• High personal support needs- showering/dressing/toileting

Diagnosis Specifics

• Has Psycho- Social &/or Multiple Diagnosis (med & high)

• Suicidal Ideation & Self Harm - post or present (med & high - make current assessment)

• Schizophrenia/ Schizoaffective Disorder (high)

• Current/recent Psychosis, Auditory and/or Visual Hallucinations (high)

• Motor Neuron Disease (high)

• Traumatic/acquired Brain Injury (high)

• Advanced Dementia (high)

• Epilepsy (med & high - make current assessment)

• History of Alcoholism &/or Drug Use (med - high - make current assessment)

• None of these apply

Final Analysis

• Low (No Risk & Care Assessment required)

• Med (Review only Risk & Care Assessment required)

• High (Detailed Risk & Care Assessment required & OT Assessment)

Summary of Final Analysis

Name of person who conducted this assessment