This form collects personal information about you for the purpose of delivering care and services. We will not use or release your information for other purposes without your consent. Please note, however, in an emergency, we are permitted to exchange required information with relevant agencies without your consent.

It is your right to withdraw consent at any time and to obtain access to the information we hold about you.

Please ensure we have the latest copy of your medical summary, including: 

• Hospital dischage summary (if recently in hospital)

• Full medication list (including supplements, vitamins, etc.)

• Blood test results (if available)

An advance care directive is a legal document where you record your future health and personal care wishes, including who you want to make decisions for you if you lost your legal decision-making capacity.

In your ‘Advance care directive’, you can include:

• a values directive: If you record your values and preferences for your medical treatment, this will help your medical treatment decision maker, or the Public Advocate to make the decision you would want.

• an instructional directive: An instructional directive is a legally binding statement in which you consent to, or refuse, future medical treatment.

Assessment scale

The AKPS is a single score between 0 and 100 assigned by a clinician based on observations of an individual’s ability to perform common tasks. A score of 100 signifies normal physical abilities with no evidence of disease. Decreasing numbers indicate a reduced ability to perform activities of daily living

We aim to ensure that your wishes, beliefs, cultural and spiritual values, and care decisions are respected and upheld throughout your care journey. Establishing your goals of care helps all staff involved in your care understand your decisions and provide support in accordance with them

Please complete the Symptom Assessment Scale (SAS) guide and encourage the client to self-report symptoms regularly. This provides the specialist palliative care team, nursing staff, and care team with valuable information to enhance symptom management, comfort, and overall quality of life.

For RN/Clinical Care Partner reference:

Disaster & Emergency Management: 

The Client has declined the recommendation for the above identified risks.

*Please see Disaster & Emergency Section for signature of acknowledgement.

Personal Care: 

The Client has declined the recommendation for the above identified risks.

*Please see Personal Care Section for signature of acknowledgement.

Toileting & Continence: 

The Client has declined the recommendation for the above identified risks.

*Please see Toileting & Continence Section for signature of acknowledgement.

Mobility & Transfers: 

The Client has declined the recommendation for the above identified risks.

*Please see Mobility & Transfers Section for signature of acknowledgement.

Environment Observations:

The Client has declined the recommendation for the above identified risks.

*Please see Environment Observations Section for signature of acknowledgement.

Communication & Sensory Care:

The Client has declined the recommendation for the above identified risks.

*Please see Communication & Sensory Care Section for signature of acknowledgement.

Nutrition & Meal Planning & Preparation:

The Client has declined the recommendation for the above identified risks.

*Please see Nutrition & Meal Planning & Preparation Section for signature of acknowledgement.

Skin Integrity:

The Client has declined the recommendation for the above identified risks.

*Please see Skin Integrity Section for signature of acknowledgement.

Foot Health:

The Client has declined the recommendation for the above identified risks.

*Please see Foot Health Section for signature of acknowledgement.

Sleep:

The Client has declined the recommendation for the above identified risks.

*Please see Sleep Section for signature of acknowledgement.

Symptoms & Pain:

The Client has declined the recommendation for the above identified risks.

*Please see Symptoms & Pain Section for signature of acknowledgement.

Breathing:

The Client has declined the recommendation for the above identified risks.

*Please see Breathing Section for signature of acknowledgement.

Medication Management:

The Client has declined the recommendation for the above identified risks.

*Please see Medication Management Section for signature of acknowledgement.

Medication Management:

The Client has indicated that they need assistance to pick up medication and has signed to give permission for assistance. 

*Please see Medication Management Section for signature of acknowledgement.

Dementia / Cognitive Impairment:

The Client has declined the recommendation for the above identified risks.

*Please see Dementia / Cognitive Impairment Section for signature of acknowledgement.

Mental Health:

The Client has declined the recommendation for the above identified risks.

*Please see Mental Health Section for signature of acknowledgement.

Social & Transportation:

The Client has declined the recommendation for the above identified risks.

*Please see Social & Transportation Section for signature of acknowledgement.

Clinical Care:

The Client has declined the recommendation for the above identified risks.

*Please see Clinical Care Section for signature of acknowledgement.

I, 

consent to information relevant to the care I receive being made available as outlined below:

Doctor/GP/Specialist

Aged Care Assessment Service 

(ACAS)

Family Member/Next of Kin

Relevant information may be shared with other team members involved in my care

Other

(i.e. Hospitals, specialists, etc.)

Other Service Providers