PERSONAL PORTRAIT. Attach photo here. This document is designed to provide important and relevant information. This Portrait was created on..

Transcription

1 PERSONAL PORTRAIT OF.. Attach photo here This document is designed to provide important and relevant information about... This Portrait was created on.. I consent to the information in my Portrait being shared with only: (list names).

2 TABLE OF CONTENTS Page 1. Personal details 2 2. Cultural Information 2 3. Carer(s) details 2 4. Emergency Contacts 3 5. Emergency Plans 3 6. Disability and Health 4 7. Medical Details 4 8. Personal Support 5 9. Mobility, Communication, Safety and Technical Aids Health Care Providers Activities e.g. Work, Volunteering, Day program Pets Routines and Rituals Things I like Things I don t like Support I need to do things Things to remember when supporting me Legal and Finances Personal Portrait Review 14 1

3 Note: This document is designed to be completed by the person it is about, if that is possible. If not, it should be completed by the person who cares for them. 1. Personal Details What name do you prefer to be called Date of Birth Pension number Pension type 2. Cultural Information Country of Birth Language spoken at home Interpreter required? (Please circle) Yes No Aboriginal or Torres Strait Islander origin and/or descent? Yes / No Religious or spiritual affiliation (if any). Church attended (if any) information relating to culture: 3. Carer(s) Details Carer 1. Carer 2. Carer Relationship to person cared for Carer Contact Details Phone Mobile

4 4. Emergency Contact 1. ( in addition to Carers) Relationship Contact details Emergency Contact 2. Home Work Mobile Relationship Numbers Emergency Contact 3. Home Work Mobile Relationship Numbers 5. Emergency Plan Home Work Mobile Have any specific alternative arrangements been made in the case of an emergency? YES NO If Yes, please provide details 3

5 6. Disability and Health Information of disability and/or health problems that will enable any appropriate person to help you when necessary. 7. Medical Details Medicare Number Health Care Card Number Private Medical/ Hospital Insurance Yes No If yes, Number Ambulance Membership Yes No If yes, Number Allergies Location of Medication Prescriptions Location of Medication Preferred pharmacy 4

6 8. Personal Support: For each of the following activities, please place a tick in the box that indicates your current level of independence (or the current level of independence of the person that you care for). If you wish you may write more information in the relevant box about how you manage (the person you care for manages) that activity. a) Level of independence: (Please tick one box for each activity) Activity Independent Requires Prompting Communication Mobility Personal Hygiene Meal preparation and eating Medication management Dental and health appointments Household cleaning, washing etc. Transport Budgeting/ financial management Shopping Social and community interaction Recreation Respite or holidays Requires some assistance Requires full assistance 9. Mobility, communication, safety and technology aids Do you (or the person you care for) use aids/equipment such as a wheelchair, computer, keyboard, IPad, I-Phone to help you (them)? YES NO If yes, Please list those aids here; Do you need assistance to use and maintain these aids? YES NO If yes, please provide details that will assist any appropriate person to help you when necessary. 5

7 10. Health Care Providers How do you (the person cared for) usually get to this GP person? (tick all that apply) Carers car Specialist Friend s car Taxi Dentist Physiotherapist Health Care Provider 1. (Specify what type of therapist) Health Care Provider 2. (Specify what type of therapist) Carers car Friend s car Taxi Carers car Friend s car Taxi Carers car Friend s car Taxi Carers car Friend s car Taxi Carers car Friend s car Taxi 6

8 11. Activities, including work, volunteering, day program or recreation activities etc. (Say what each activity is in the box next to the activity number) Activity 1 How do you (the person cared for) usually get to this person? (tick all that apply) Day / Time Contact name details of the activity (what to bring, what to wear etc.) Activity 2 Day / Time Contact name details of the activity (what to bring, what to wear etc.) Activity 3 Day / Time Contact name details of the activity (what to bring, what to wear etc.) 7

9 12. Do you (or the person you care for) have any pets? (Please circle one answer) YES NO If Yes, what type of pet is it? Does it live with you? Do you have a vet that you usually take your pet to? (If yes, list the vet s name, address and phone number below) : : Phone number: Who will look after your pet if you cannot? 13. Routines and rituals Please detail your preferred daily routine Please detail any weekly rituals you participate in e.g. cultural, religious Please detail annual activities e.g. how you celebrate birthdays, Christmas, cultural, religious and family traditions Please list any other activities, routines and rituals not already detailed 8

10 14. Things I like, and things I like to do Food Activities Using the computer TV programs Music Friends Partner/boyfriend/ girlfriend/ close intimate relationship Personal items / Special Possessions 9

11 15. Things I don t like or that upset me Food Activities Noise 10

12 16. Support I need to do things Level of support required Activity Communication Can do by myself Can do with prompts Can do with some help Need carer to do Meal preparation Eating Drinking Showering / bathing Toileting Dressing/ putting on my shoes Cleaning my teeth Brushing my hair Cleaning my room Washing my clothes Doing the dishes Travelling/Mobility Managing my money 11

13 17. Things to remember when supporting me 12

14 18. Legal and Finances Have you made a Will? No Yes If yes, where is the Will kept? Carer 1 Have your carers made a Will? No Yes If yes, where is the Will kept? Carer 2 No Yes If yes, where is the Will kept? Have financial arrangements been made in the case of an emergency? Yes No If yes, what are they? If yes, who is the contact? 13

15 19. Personal Portrait Review It is strongly recommended that this Personal Portrait be reviewed regularly as your likes, dislikes, medication and personal circumstances may change over time. It is suggested that this Personal Portrait be reviewed at least once every year. Review 1 Date of Review Were any changes made? YES NO Was this review done by the person whose portrait this is? If no, name of reviewer Relationship of reviewer to the person cared for Signature Review 2 Date of Review YES NO Were any changes made? YES NO Was this review done by the person whose portrait this is? If no, name of reviewer Relationship of reviewer to the person cared for Signature Review 3 Date of Review YES NO Were any changes made? YES NO Was this review done by the person whose portrait this is? If no, name of reviewer Relationship of reviewer to the person cared for Signature YES NO 14