Pubail Vagrant Home

Guidelines for Assessment Form

1)Personal information

Name / The resident’s name, as well as any other names they are known by (nicknames etc)
Age / The resident’s age, as well as birth date if known
Family History / The family situation of the resident – whether they are married, have children, names of their parents etc.
Educational Background / The educational level of the resident –whether they attended primary/secondary school, college, university.
Work history (if any) / What kind of work has the resident done in the past, and what kind are they doing now?
History at the Home /
  • Length of time the resident has stayed at the Home.
  • Has the resident stayed at the home and left before? If yes, how many times have they left the home before?

Where was the resident before the Home? / Where the resident was living or staying before arriving at the Home.
Address / The resident’s last known address, or address of family, if known.
Contact phone number of family member(if any) / If available, phone number at which the resident’s family can be contacted.

2)Information about disability and health problems

a)Does the resident have a formal diagnosis? If so, what is it? If the resident has received a diagnosis from a Doctor or other staff at the Home, please write it here.

b)What disability do you think the resident has? (see guidelines)Tick the disability or disabilities which you think the resident has, according to the following guidelines (if more than one disability, please tick each one):

Mental IllnessIntellectual disability

Schizophrenia / Hearing voices in head and talking to these, believing things that are not true, behaving strangely at times, loss of motivation, isolated, restless / General slow learner / Takes a long time to do tasks, learns new things very slowly, behaves younger than they are.
Bipolar Disorder (Manic Depression) / Depressed sometimes, very happy at other times. When happy – over excited, difficulty sleeping, thinks self is important person / Down Syndrome / Flat, round face, small nose, short height, slanted eyes, slow learner
Depression / Sad, unhappy, talking about suicide, no motivation to care for self, disturbed sleep, unusual appetite, no imagining symptoms / Hydrocephaly / Large head, slow learner
Anxiety / Worried, frightened, thinking the same thoughts again and again, headaches, dizziness, fast heartbeat, no imagining symptoms / Microcephaly / Small head, slow learner
Dementia / Seen in older people. Forgetful, worried, getting lost in familiar places, unable to follow conversations, talking inappropriately, no imagining symptoms / Cerebral Palsy AND intellectual disability / Not everyone with CP is a slow learner. However, if a resident has CP, AND is a slow learner, tick here.
Not known / Tick here if you are not sure what kind of mental illness the person has / Not known / Tick here if you are not sure what kind of intellectual disability the person has

Other disability (please describe)

Physical disability / Impairment in body, for example in legs, arms, hands, feet etc. Cerebral Palsy without intellectual disability.
Visual impairment / Difficulty seeing or unable to see at all.
Hearing impairment / Difficulty hearing or unable to hear at all.
Speech impairment / Difficulty speaking clearly or unable to speak at all.
Head injury / Behaviour problems following blow to the head
Autism / Likes routine, spends time alone, difficulty being involved in group activities, and sometimes behaves strangely.
Epilepsy / Has seizures

3)Does the resident have any other medical or health issues or problems? Please describe:

Please circle yes or no according to the resident’s condition. If a diagnosis has been made by a medical professional, please circle “yes” in the 2nd column. If the resident needs referral to medical services for diagnosis and treatment, please circle “yes” in the 3rd column. If the resident has any other health issue, please write it in the empty rows at the bottom.

Health issue / Diagnosis already made? / Needs referral to medical services?
Skin diseases / Yes / No / Yes / No
Urinary tract infection / Yes / No / Yes / No
Sexually transmitted disease / Yes / No / Yes / No
HIV/AIDs / Yes / No / Yes / No
Tuberculosis / Yes / No / Yes / No

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Pubail Vagrant Home

Guidelines for Assessment Form

4)Information about functional ability/limitations: Complete the following table by identifying the roles of the resident. After observing/discussing task performance, circle yes or no according to the resident’s ability to perform the task. If the resident is able to perform some aspects of the task but still needs assistance, circle “no”. Circle “yes” in the last column if there is at least one “no” identified for each role.


/ Interest and motivation / Knowledge of the task / Planning and organiz-ing the task / Physical Capacity / Concentration / Communi-cation skills with others / Requires intervention?
Self Care roles
Eating / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No
Bathing / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No
Dressing / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No
Toileting / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No
Grooming / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No
Washing clothes / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No
Brushing teeth / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No
Cleaning room / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No
Cleaning dishes / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No
Work Roles
Could be cooking, tailoring, sewing, embroidery, weaving, gardening, cleaning the environment, nursing children etc. / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No
Leisure roles
Could be singing, listening to music, dancing, reading, writing poems, chatting, storytelling, playing games, home decorating, painting, drawing, grooming, swimming, jogging, gardening, watching TV etc. / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No / Yes/No

Comments:Add information here about additional observations made during the task performance.

5)Resident’s Interests

What are the resident’s leisure interests now and for the future?
List the resident’s past leisure interests, and interests for the future.

6)Resident’s goals

What does the resident hope to achieve in the future?
List the resident’s hopes and wishes for the future (eg work, family, friends, etc). This will help determine goals which are decided by the resident.

7)Problem identification and priorities

Problem / Priority (1 -3)
List problems identified by the resident with you. / Score problems according to the following scale:
1 = high priority
2 = medium priority
3 = least priority

8)Resident’s Goals

Number / Goal
1 / Choose the top 5 problems according to priority, and develop goals to address these. Goals must be written from the perspective of the resident, and should be SMART (Specific, Measurable, Achievable, Realistic, Time).
2
3
4
5
Assessed by:write your name here / Date:

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