Learning Disabilities Assessment

Section

Gender:

Support and Patient Information

Were you able to complete this form yourself?
Are you under the care of social services?
Would you like to be referred to social services?
Do you have a carer?
What is your current living situation?
Are you considered housebound? (Unable to leave without medical assistance)
What is your employment status?

Mobility

How mobile do you considered yourself?
Are you under the care of a physiotherapist?
Would you like to be referred to physiotherapy?

Daily Living Skills

Feeding Status:
Hydration Status:
Dressing Status:
Bathing Status:
Toilet Status:
Are you under the care of an occupational therapist?
Would you like to be referred to OT if eligible?

Keep Well and Active

How would you rate your diet?
How would you rate your exercise levels?
What is your smoking status?
Would you like advice on stopping smoking?
How would you rate your vision?
Hearing difficulty?

Female Health

Are you sexually active?
Would you like advice on contraception?
Are you happy to be referred for a mammography?
If you are due your cervical smear, are you happy for this to be arranged?
If able, are your regularly checking your breasts for changes?
You will be asked to sign that you have declined your cervical smear.

Speech and Language

What are your speech levels like?
Are you under the care of a speech therapist?
Would you like to be referred to speech therapy, if appropriate?

Immunisations and Vaccinations

If you are eligible, are you happy to receive the pneumococcal vaccination?
If you are eligible, are you happy to receive the season flu vaccination? (between the months of September and March only)

General Health

Please select one or more of the following if they apply within the last 14 days:
Has there been a change in your urinary frequency?
Do you have a history of a stroke?
Are you under the care of neurology?
Do you have epilepsy?

Epilepsy

What is the frequency of your seizures?
Are you under the care of a psychiatrist?
Are you under the care of a neurologist?
Are you under the care of a clinical nurse specialist?
Are you suffering from any epilepsy medication side effects?

Cardiovascular, if applies

Do you suffer from any pain during exercise or activity?