Name

Sex SexMaleFemaleOther

Date of Birth

Address

Postcode

Country of Birth

What is your preferred method of contact? What is your preferred method of contact? Email Phone

Email

Phone Number

Do you identify as Aboriginal or Torres Strait Islander? Do you identify as Aboriginal or Torres Strait Islander? Aboriginal Torres Strait Islander None

General Practitioner Name

General Practitioner Clinic

General Practitioner Phone Number

Carer/Next of Kin Name

Next of Kin Relationship

Next of Kin Phone Number

Next of Kin email

Next of Kin Address

Power of Attorney Power of Attorney Yes No

Who is authorized to sign documentation? Who is authorized to sign documentation? Client Carer Nominee OPG

Do you have a Home Care Package? Do you have a Home Care Package? Yes No

Please select your package care level: Please select your package care level: 1 2 3 4

Pension Number

DVA Number

Aged Care ID Number

MAC Referral Number

Please select which of our services you would like to request. Please select which of our services you would like to request. Continence Assessment Nursing Support Homecare Support Other

Please select which type(s) of Continence Assessment you would like to request Please select which type(s) of Continence Assessment you would like to request Urinary Bowel

Please provide details on any other support you may require.

Do you suffer from any of the following conditions? Do you suffer from any of the following conditions? Heart Condition (e.g. high blood pressure, previous heart attack) Respiratory Condition (e.g. asthma, COPD) Endocrine Condition (e.g. diabetes, thyroid dysfunction) Neurological Condition (e.g. stroke, epilepsy) Mental Health Condition (e.g. anxiety, depression) Cancer or Tumors Other

Please provide details of your condition:

Do you have any other service providers involved? Do you have any other service providers involved? Yes No

Please provide details on the other service providers involved:

Do you consume alcohol? Do you consume alcohol? Yes No

How many standard drinks would you have in a day?

Do you smoke cigarettes / e-cigarettes? Do you smoke cigarettes / e-cigarettes? Yes No

How many cigarettes would you smoke in a day?

CiMaS has a responsibility to the safety of our nurses and support workers. Please provide any information that may assist our staff in adapting to your environment. (e.g pets, medication box, property access)

How would you like to follow up on your application? How would you like to follow up on your application? I will call CiMaS to follow up on my application. I would like CiMaS to call me to follow up on my application.