1. Contractor Name *
2. Allied Health Discipline * Diabetes EducationDieteticsPodiatryOther
3. Service Date *
4. Location * ChooseBatlowBerriganBlandCootamundraCorowaCulcairnDeniliquinFinleyGriffithGundagaiHayHentleyHillstonHolbrookJerilderieJuneeLeetonLockhartMolameinNarranderaTemoraTocumwalTooleybucTumbarumbaTumutUranaWest WyalongYoungOther
5. Is this a new client * YesNo
6. Client name *
7. Mode of service * In PersonTeleHealth – VideoTeleHealth – PhoneOther
8. Did the client attend this appointment * YesNo
9. Date of Birth *
10. What is the client’s gender? * MaleFemaleOther
11. Is the client of Aboriginal or Torres Strait Islander heritage? * YesNo
12. What is the client’s country of birth * AustraliaOther
13. Is an interpreter needed for this client? * YesNo
Formal interpreter service usedFamily member/friendOther
14. Patient have a Health Care card? * YesNo
15. Does the client have a GP management plan? * YesNo
16. What is the client’s presenting condition * ChooseAt risk of obesity – particularly in youthChronic painDiabetesFrailtyObesityOsteoarthritisPhysical inactivityRespiratory diseaseOther
17. What town does client usually live in * ChooseBatlowBerriganBlandCootamundraCorowaCulcairnDeniliquinFinleyGriffithGundagaiHayHentleyHillstonHolbrookJerilderieJuneeLeetonLockhartMolameinNarranderaTemoraTocumwalTooleybucTumbarumbaTumutUranaWest WyalongYoungOther
18. Is the client a smoker or ex smoker? * YesNo
19. Did you give the clients smoking cessation advice? * YesNo
20. Did you give the client advice about healthy weight? * YesNo
21. Did you give the client physical activity advice? * YesNo
22. Did you give the client falls prevention advice? * YesNo
23. Please have your clients complete the following 3 questions *
During the past 4 weeks, has your physical and emotional health limited your social activities with family, friends, neighbours or groups? 12345
How would you rate your overall health now compared to 4 weeks ago? 12345
How have things been going for you during the past 4 weeks? 12345
Review Questions
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