Appointment pre-screen questionnairePlease answer the following questions Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Dwelling type * select from drop down menu Private residence - owned Private residence - rental SIL / SDA Nursing home Is there mobile phone coverage at the residence? * select from drop down menu Telstra only All carriers All pets need to be restrained for the OT appointment. If your pet is not restrained or contained, the OT will not enter the property. Do you agree to restrain all animals for the OT appointment? * select from drop down menu yes no no pets on site Is the participant agreeable to this appointment? * select from drop down menu yes no Are there any firearms stored on site? * select from drop down menu yes no If yes, are the firearms stored in adherence to Section 94 of the Weapons Regulation Act 2016? * select from drop down menu yes no not applicable Can you please confirm there will be no use of illicit drugs, alcohol or cigarettes while our Occupational Therapist is attending? * select from drop down menu yes no Do we need to be aware of infection control measures for infectious diseases or illnesses * Does the participant have a history of violent behaviors? E.g domestic violence, assault. Please provide relevant details. * Does the participant have a criminal record, or has the participant previously been incarcerated? Please provide details of convictions. * Are there any entry requirements we need to be aware of? Eg - gated community access code, keybox entry. Please include any information or codes that are relevant to access. Please list the names of people who will be attending the appointment and their relationship to the participant. * Please list any other details that are relevant to the participant and their appointment. * This form has been completed by (name) * Date MM DD YYYY Thank you!
