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AGED CARE CLIENT DETAILS FORM

Care Solutions Australia - Aged Care Client Details Form

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Client Information

Full Name:

Preferred Name:

Date of Birth:

Gender:

Address:

Suburb:

Postcode:

Home Phone:

Mobile Phone:

Email Address:

Preferred Method of Contact:

Phone

Mobile

Email

SMS

Emergency Contact

Name:

Relationship to Client:

Phone Number:

Alternative Phone Number:

Address (if different):

Next of Kin / Representative

Name:

Relationship:

Phone Number:

Email:

Does this person have authority to make decisions on behalf of the client?

Yes

No

If yes:

Enduring Power of Attorney

Guardian

Other

General Practitioner (GP)

GP Name:

Practice Name:

Phone Number:

Address:

Medical Information

Primary Diagnoses/Health Conditions:

Allergies:

Current Medications:

Mobility Status:

Independent

Walking Stick

Walker

Wheelchair

Other

Vision Impairment:

No

Yes

Hearing Impairment:

No

Yes

Cognitive Concerns (e.g., Dementia, Memory Loss):

No

Yes

Details:

Care and Support Requirements

Services Required:

Social Support

Transport

Domestic Assistance

Personal Care

Meal Preparation

Shopping Assistance

Respite Care

Community Access

Medication Assistance

Other

Goals and Preferences:

Cultural and Communication Needs

Primary Language:

Interpreter Required:

Yes

No

Cultural, Religious or Spiritual Preferences:

Risk and Safety Information

Falls History in the Last 12 Months:

Yes

No

Known Risks or Safety Concerns:

Pets at Home:

Yes

No

Details:

Funding Information

Funding Type:

Home Care Package

Commonwealth Home Support Programme (CHSP)

Private Client

NDIS (if applicable)

Other

My Aged Care Number:

Package Level (if applicable):

Level 1

Level 2

Level 3

Level 4

Consent

I consent to the collection, storage and use of my personal information for the purpose of providing care and support services. I understand that my information will be managed in accordance with privacy legislation.

Client Name:

Client Signature:

Date:

Representative Signature (if applicable):

Relationship to Client:

Date:

(Optional) If there are any file or documents that you would like to attach with this form, please upload here:

Choose File

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