Broad screen checklist of observed changes ( final draft1)

• Document No.

• Name of Participant

• Conducted on

  Date

• Name of Participant

• Add media

  Media

• Interpretation and Referral Recommendations
  
  Scores indicate degrees of change for each sub scale and the total scale are present in table 1. These measures are to be used to differentiate clients needs and assist in referral practices.
  Compare the clients scores to the scores in the table below to establish both the area and degree of change/decline.
  
  TABLE ONE DEGREE OF FUNCTIONAL CHANGE.
  SCALE. SIGNIFICANT. MODERATE. MINOR
  
  HEALTH. >16. >8. <8
  PHYSICAL. >13. >4. <4
  SENSORY
  INTERGRATION. >6. >1. <1
  PERCEPTION /
  COGNITION. >20. >3. <3
  SOCIAL/
  EMOTIONAL. > 22. >10. <10
  ADL. >13. >4. <4
  
  TOTAL. > 90. > 30. < 30
  
  Clients whose scores indicate a significant change should be referred immediately, particularly if they are not already being monitored by relevant specialists
  Clients with moderate changes should be referred for advice.
  Clients with minor changes should be closely monitored changes documented and the broad screen checklist of observed changes should be repeated within six months.
  Significant scores Ina. Particular sub scale could indicate where a carer may first seek advice. referrals could be made for follow up assessments by relevant specialists, for example changes in health could be referred to a medical officer, physical changes may be referred to physiotherapist, cognitive or social and emotional changes may be referred to psychologist or psychiatrist.
  
  NOTE: the information gathered is to be used in conjunction with clinical experience and judgement of a specialist and does not provide sufficient evidence for a diagnosis in isolation
  

• SCALE
  
  Y (yes) There has been a change in the clients abilities behaviour during the last 6 months
  E (earlier) There has been a change in the clients abilities/ behaviour which was apparent
  more than 6 months ago up to 3 years
  N (no) There have been no changes in the clients abilities/ behaviour in the last 6 months
  A. (always) Client has always required support in this area owing to intellectual, physical or sensory impairments

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HEALTH

Eating Habits

• 1 Eat Less

  Y

  E

  N

  A

• 2 More fussy about food

  Y

  E

  N

  A

• 3 Began to prefer sweet food

  Y

  E

  N

  A

• 4 Eat in edible

  Y

  E

  N

  A

• 5 Excessive thirst

  Y

  E

  N

  A

Sleeping pattern

• 6 Sleep more during the day

  Y

  E

  N

  A

• 7 Wake early for no reason

  Y

  E

  N

  A

• 8 Lose consciousness

  Y

  E

  N

  A

• 9 Insomnia sleeps little

  Y

  E

  N

  A

Digestion

• 10 Complain of pain after meals

  Y

  E

  N

  A

• 11 Vomit

  Y

  E

  N

  A

Breathing

• 12 Difficulty breathing in everyday routine

  Y

  E

  N

  A

• 13 Difficulty breathing after unusual exertion

  Y

  E

  N

  A

• 14 Shallow breath puff

  Y

  E

  N

  A

• 15 Breath noisily wheeze

  Y

  E

  N

  A

• 16 Cough persistently

  Y

  E

  N

  A

Circulation

• 17 Cold hands/feet

  Y

  E

  N

  A

• 18 Skin is unusual colour

  Y

  E

  N

  A

Bladder

• 19 Incontinent

  Y

  E

  N

  A

• 20 Urinate frequently

  Y

  E

  N

  A

• 21 Urine of unusual color odour

  Y

  E

  N

  A

• 22 Frequent urinary tract infection

  Y

  E

  N

  A

Bowel habits

• 23 Difficulty using bowels

  Y

  E

  N

  A

• 24 Incontinent of faeces

  Y

  E

  N

  A

• 25 Faeces unusual color/odour/consistency

  Y

  E

  N

  A

Skin

• 26 Skin easily damaged bruised /marked

  Y

  E

  N

  A

• 27 Changes in warts/mole/ growth

  Y

  E

  N

  A

• 28 Lumps have developed changed

  Y

  E

  N

  A

Infection

• 29 More prone to infections

  Y

  E

  N

  A

• 30 Longer than usual recovery

  Y

  E

  N

  A

• 31 Onset of seizures

  Y

  E

  N

  A

Health Sub Scale Score

• Degree of functional change Sub Score

  Select >16 > 8 < 8

  • >16
  • > 8
  • < 8

PHYSICAL COMPETENCIES

• 32 Less able to roll over and get out of bed

  Y

  E

  N

  A

• 33 Less able to sit /stand upright

  Y

  E

  N

  A

• 34 Less able to use arms/hands during any activity

  Y

  E

  N

  A

• 35 Less able to walk climb steps

  Y

  E

  N

  A

• 36 More likely to lose balance/ stumble /fall

  Y

  E

  N

  A

• 37 Change in way person walks

  Y

  E

  N

  A

• 38 Increased difficulties in eating/swallowing/choking /gagging/spillage

  Y

  E

  N

  A

• 39 Increased difficulty manipulating small items in fingers/buttons/spoons/toothbrush

  Y

  E

  N

  A

• 40 Increased difficulty turning on and off taps/turning doorknobs

  Y

  E

  N

  A

• 41 More likely to drop items

  Y

  E

  N

  A

Physical Competencies Sub scale score

• Degree of functional change<br>Sub Score

  >13

  > 4

  < 4

SENSORY INTERGRATION

• 42 More likely to hold items at unusual distance

  Y

  E

  N

  A

• 43 Less reaction to objects moving towards him/her

  Y

  E

  N

  A

• 44 Squints more often

  Y

  E

  N

  A

• 45 Less able to move around objects

  Y

  E

  N

  A

• 46 More tentative when negotiating steps/surfaces

  Y

  E

  N

  A

• 47 Less able to walk in the dark

  Y

  E

  N

  A

• 48 Less responsive to normal speaking voice

  Y

  E

  N

  A

• 49 Less able to follow a verbal request "give me"...

  Y

  E

  N

  A

• 50 Changing responses to noises

  Y

  E

  N

  A

• 51 More likely to talk loudly

  Y

  E

  N

  A

• 52 More likely to repeat questions as if they had not heard answer

  Y

  E

  N

  A

Sensory Integration Sub scale score

• Degree of functional change

  > 6

  > 1

  < 1

PERCEPTIONAL/COGNITIVE

• 53 Less aware of own name

  Y

  E

  N

  A

• 54 Less able to recognise familiar people /places /objects

  Y

  E

  N

  A

• 55 Less able to find familiar places in the house

  Y

  E

  N

  A

• 56 Less able to follow through an activity such as moving from one room to another for a purpose

  Y

  E

  N

  A

• 57 Less able to understand what is happening when in an unfamiliar environment

  Y

  E

  N

  A

• 58 Less able to distinguish an object and it's use: toothbrush-teeth cleaning/cup-drinking/ shoes wearing not he feet

  Y

  E

  N

  A

• 59 Less able to follow normal sequence of daily routine

  Y

  E

  N

  A

• 60 Less able to cope with changes in daily routine

  Y

  E

  N

  A

• 61 Less able to predict what happens on different days of the week

  Y

  E

  N

  A

• 62 Less able to recall familiar sequences involved in tasks such as dressing/showering/toileting/eating

  Y

  E

  N

  A

• 63 Less able to recall recent events within the hour/day

  Y

  E

  N

  A

• 64 More likely to behave inappropriately in an unusual situation

  Y

  E

  N

  A

• 65 More likely to exhibit private behaviour in public places

  Y

  E

  N

  A

• 66 More likely to put things in inappropriate places

  Y

  E

  N

  A

• 67 More likely to become possessive about household property

  Y

  E

  N

  A

• 68 Less able to find things that are in there usual place

  Y

  E

  N

  A

• 69 More likely to get lost in familiar places

  Y

  E

  N

  A

• 70 Less able to learn something new

  Y

  E

  N

  A

• 71 More easily confused when asked to do two things in sequence

  Y

  E

  N

  A

• 72 Abilities more likely to fluctuate from day to day

  Y

  E

  N

  A

• 73 Less able to make simple choices

  Y

  E

  N

  A

• 74 More likely to talk about things that happened long ago and become preoccupied with old memories

  Y

  E

  N

  A

Perceptual Cognitive Sub scale score

• Degree of functional change Sub Score

  Select > 20 > 3 < 3

  • > 20
  • > 3
  • < 3

SOCIAL EMOTIONAL

• 75 More frequent mood changes

  Y

  E

  N

  A

• 76 More withdrawn quieter than usual less interested in usual activities

  Y

  E

  N

  A

• 77 Shows less expression of emotion does not smile/frown

  Y

  E

  N

  A

• 78 Less initiative/motivation

  Y

  E

  N

  A

• 79 More distressed, upset by everyday events/interactions

  Y

  E

  N

  A

• 80 More frustrated annoyed by everyday events/interactions worried fearful

  Y

  E

  N

  A

• 82 More likely to become angry

  Y

  E

  N

  A

• 83 More likely to appear suspicious/distrustful/accusing

  Y

  E

  N

  A

• 84 Complains more about a variety of topics

  Y

  E

  N

  A

• 85 More self centred

  Y

  E

  N

  A

• 86 Less responsive to things happening in the environment

  Y

  E

  N

  A

• 87 Less responsive to people with whom they have an established relationship/ignoring /avoiding

  Y

  E

  N

  A

• 88 Relate differently to people with whom they have an established relationship

  Y

  E

  N

  A

• 89 More argumentative

  Y

  E

  N

  A

• 90 More likely to repeat statements/questions regardless of response

  Y

  E

  N

  A

• 91 More likely to move around restlessly not staying in one place for long

  Y

  E

  N

  A

• 92 More likely to wander away from familiar locations and get lost

  Y

  E

  N

  A

• 93 More likely to wander on outings and get lost

  Y

  E

  N

  A

• 94 More likely to wander during the night instead of sleeping

  Y

  E

  N

  A

• 95 More noisy and verbally disruptive

  Y

  E

  N

  A

• 96 Increase physical aggression to people

  Y

  E

  N

  A

• 97 More destructive towards objects

  Y

  E

  N

  A

• 98 Less cooperative with usual routines/ resists

  Y

  E

  N

  A

• 99 Declining ability to understand what is said or what is happening in the environment

  Y

  E

  N

  A

• 100 Says or repeats unusual or nonsensical things

  Y

  E

  N

  A

Social Emotional Sub scale score

• Degree of functional change Sub Score

  Select > 22 > 10 < 10

  • > 22
  • > 10
  • < 10

ACTIVITIES OF DAILY LIVING

• 101 Personal hygiene tasks:washing/shaving/ dental care

  Y

  E

  N

  A

• 102 Dressing undressing and selecting clothing

  Y

  E

  N

  A

• 103 Grooming/ brushing hair/use of deodorant/makeup

  Y

  E

  N

  A

• 104 Using the toilet

  Y

  E

  N

  A

• 105 Eating /using cutlery/drinking

  Y

  E

  N

  A

• 106 Preparing a simple drink/snack or meal

  Y

  E

  N

  A

• 107 Household tasks-making bed/helping with dishes/ simple laundry

  Y

  E

  N

  A

• 108 Household safety dangers-using hot water/electrical appliances/sharp objects/locking doors

  Y

  E

  N

  A

• 109 Community safety and dangers-road safety/ travel skills/ avoiding strangers

  Y

  E

  N

  A

• 110 Using community facilities-shop/recreation facilities/bank/restaurant

  Y

  E

  N

  A

• 111 Managing own money identifying coins/notes/change/ making purchases

  Y

  E

  N

  A

ADLSub scale score

• Degree of Functional Change<br>Sub Score

  > 22

  > 10

  < 10

Previous Score

Current Score

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