Optional Health Assessment Modules Form Page 15
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27OPTIONAL MODULE 7:
UR Number:
GOALS
Surname:
Given name:
Date of birth:
(Please fill in if no label available)
PURPOSE OF MODULE
INTRODUCTION FOR CLIENT
PURPOSE OF MODULE
INTRODUCTION FOR CLIENT
To map out a clients goals.
“Now I’d like you to think about your goals and some of the priority areas
To assess the client’s perceived physical health.
“Now I am going to ask you your physical health and conduct a basic
you’d like to address”
physical health check.”
WHO CAN ADMINISTER THIS MODULE?
WHO CAN ADMINISTER THIS MODULE?
INSTRUCTIONS
INSTRUCTIONS
This module can be completed by the client with the clinician assisting
Only complete this module if you are a medical doctor or a nurse.
1. Invite client to think about their satisfaction with a range of areas in
1. Introduce module to client.
through prompts that may reflect any earlier discussion about problems,
their life out of 10.
2. As questions and perform relevant tests.
goals and priorities.
2. Invite the client to think about what would need to happen to improve
3. Formulate responses and note actions to be taken.
that area of their life.
3. Ask client to rank priorities (or reflect on which are the most important/
urgent) in discussion with you.
4. Give client a copy of their goals form to take home as a resource they
can refer to as desired.
PROBLEM
SATISFACTION
WHAT WOULD HAVE TO CHANGE TO
PRIORITY
AREA
OUT OF 10
INCREASE MY SCORE OUT OF 10?
ALCOHOL AND/OR
DRUG USE
HEALTH
(PHYSICAL & MENTAL)
SOCIAL LIFE
& FRIENDS
RELATIONSHIPS
(PARTNER OR FAMILY)
HOUSING
JOB/
EDUCATION
MONEY
& FINANCES
EXERCISE
LEGAL ISSUES
& CRIME
FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
14
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