Education Client Specific Session Information

Name of Referrer

Email Address

Contact Number

Name of person this session is about

Date of Birth

Contact Number

Address

Please tell us a little about the concerns you are experiencing with your client and what you would like to achieve from this session?

HD Specialist

When was the client last reviewed by their HD specialist?

Behaviour (please tick all that apply) Behaviour (please tick all that apply) Verbal aggression physical aggression socially inappropriate behaviour Perseveration Apathy/poor intiation sexually inappropriate behaviour impulsivity

Physical Presentation (please tick all that apply) Physical Presentation (please tick all that apply) Requires full assistance with personal care Requires some assistance with personal care Can complete tasks of daily living with prompting Swallowing difficulties Independent with meals Independent with meal preparation Falls risk Driving ambulant (no mobility aids required) ambulant with mobility aid Requires wheelchair to access home and/or community Verbal - clear communication Verbal - some changes (slurring speech ) but still able to be understood non - verbal

Cognition/Emotional Changes (please tick all that apply) Cognition/Emotional Changes (please tick all that apply) Able to make own decisions Can initiate activities Manages their own finances Experiencing changes with memory Experiencing changes with concentration Rigidity in thinking Unable to reason lack of insight/awareness of self depression/anxiety obsessive compulsive behaviours (i.e toileting, smoking) personality changes

Allied Health Assessments (within the last 12 months tick all that apply) Allied Health Assessments (within the last 12 months tick all that apply) Neuropsychological Assessment Psychiatric Speech Pathology Physiotherapy Occupational Therapy Behaviour management services Other

Hospital admissions (has your client had any recent hospital admissions?) Hospital admissions (has your client had any recent hospital admissions?)yesno

If your client has had a recent hospital admission could you please let us know : when it was, how long they were admitted for and for what reason.

Other concerns - does the client experience any other health concerns? Other concerns - does the client experience any other health concerns?yesno

If yes, to other health concerns, could you please explain what these are?