Participant Information *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

First Name

Last Name

Phone

(###)

###

####

Preferred method of contact

Phone

SMS

Email

Does the applicant have any cultural, spiritual or religious needs?

(If yes please describe)

Yes

No

Does the applicant have a personal risk assessment plan? (please provide)

yes

no

Does the applicant have their money looked after?

yes

no

Does the applicant have any dietary requirement or a mealtime management plan? (please provide)

yes

no

Is the participant a smoker?

Yes

No

Is the participant able to have alcohol?

yes

no

Is the participant inclined to wander?

yes

no

Does the participant have any phobias?

Yes

No

Does the participant have hearing difficulties

yes

no

Behaviours of concern (please provide plan)

yes

no

Does participant need help with showering?

yes

no

Does participant need help with personal care/toilet?

yes

no

Is participant aware of stranger danger?

yes

no

Is participant aware of pool safety?

yes

no

Is participant aware of road safety?

yes

no

Is participant aware of heights?

yes

no

Problems with swallowing food, fluids or medication *

yes

no

Does the participant suffer from blackouts or dizzy spells? *

(If yes please describe)

yes

no

Asthma (please provide management plan)

yes

no

Bed wetting

yes

no

Diabetes (please provide management plan)

yes

no

Seizures/Epilepsy? *

Please provide management plan

yes

no

Allergies? *

(if yes please describe)

Option 1

Option 2