Sensible Care

New Participant VC Setup Form

Date of Completion

Person completing form

Care Manager's Email Address: *

Title

Client Name

Preferred Name

Client DOB

Allergies

Is the Client on Blood Thinners?

YesNo

Provide Further Details

Does the Client have a Pacemaker?

YesNo

Provide Further Details

Address

Street address

Suburb

State

Postcode

Phone Number

Email Address

How do you prefer to have forms sent to you?

EmailTextPost

Country of Origin

Does the client speak English as primary language?

YesNo

Other Languages Spoken

Religion

Cultural/Religious Consideration

Marital Status

Living Circumstances

Medicare Number

Pension/DVA Number

Referral Code

AC Number

Other identities

Primary Contact

Self1st Emergency Contact

Primary Contact

Name: *

Relationship: *

Address

Street address

Suburb

State

Postcode

Phone Number: *

Email Address

Secondary Contact

Name:

Relationship:

Address

Street address

Suburb

State

Postcode

Phone Number:

Email Address

Funding Information

Funding Management Type

Self-ManagedFully Managed

Service Offer

MSO (minimum service offer)FSO (full service offer)

Medical Practitioner

Doctors Name

Practice Name

Address

Street address

Suburb

State

Postcode

Phone Number

Email Address

Other Information (if applicable)

Client Profile

Background

Overview of clients life, marriage, occupations, family, living arrangements

Overview of hobbies, interests, social, and exercise

Medical conditions relating to care/allergies (Medical History)

Personal care

Toileting & Continence

Mobility & Transfers (Including Falls & Community Access)

Communication & Sensory Care (Hearing and Vision)

Nutrition & Meal Planning & Preparation

Medication management:

Cognition & Mental Health

Health

Equipment Available / Equipment Use
Example: Encourage participant to take walker when shopping

AT-HM Requests

Access to Residency

Access to home
Entry Instructions, etc.

Parking & Special Instructions
Parking on street, parking signs, etc.

Living Arrangements

Living Situation
Where living & who is living there

Identified Risks

Risks identified:

Shift Alerts

Shift alert:

Care Manager Tasks

Care Manager Tasks:

Service Coordinator Tasks

Task

When to start

Sensible Care

New Participant VC Setup Form

Primary Contact

Secondary Contact

Funding Information

Medical Practitioner

Client Profile

Background

Health

Access to Residency

Living Arrangements

Identified Risks

Shift Alerts

Care Manager Tasks

Service Coordinator Tasks

Support at Home Service List

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