Allied Health Data Submission

Clinic Date *

Contract Number *

Allied Health Discipline (Group) *

Location *

Is this a new client? *

YesNo

Did the client attend this appointment? *

YesNo

What is the client's date of birth? *

What is the client's presenting condition? *

Does the client have a health care or DVA card? *

YesNo

What is the client's gender? *

What town does the client usually live in? (please do not use commas) *

Is the client of Aboriginal or Torres Strait Islander heritage? *

What is the client's country of birth? (please do not use commas) *

Does the client have good English language proficiency? *

YesNo

Is the client a smoker or ex smoker? *

Yes No

Does the client have a GP management plan? *

YesNo

Does the client have a team care arrangement? *

YesNo

Did you give the client smoking cessation advice? *

YesNo

Did you give the client advice about healthy weight? *

YesNo

Did you give the client physical activity advice? *

YesNo

Did you give the client falls prevention advice? *

YesNo

How long in weeks did the client wait to get this appointment? (please use number(s) only) *

Client Outcome measure tool - WONCA Chart

During the past 4 weeks, has your physical and emotional health limited your social activities with family, friends, neighbours or groups?

Has health limited participation in Social Activities?

How is your health now compared to 4 weeks ago?

How has your quality of life been the last 4 weeks?