Name
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First Name
Last Name
1. Things I do for my health that are important to me
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2. My main health concern is
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3. I have asthma
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Yes
No
4. I have allergies
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Yes
No
5. I have epilepsy or seizures
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Yes
No
6. I protect my skin from the sun by wearing sunscreen
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Yes - always
Yes - occasionally
No
7. I need help to apply sunscreeen
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Yes - always
Yes - occasionally
No
8. I also protect my skin from the sun by wearing a cap or hat
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Yes - always
Yes - occasionally
No
9. My favourite fitness and sporting activities are
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10. I think I have a good level of fitness
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Yes
No
Not sure
QUESTIONS ABOUT MY STRENGTH AND BALANCE
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11. I can carry a bag of groceries from the shops to the car
12. I can reach up and grab something from the top shelf
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13. I can stand up from sitting on the floor without any assistance
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14. I can move around the house without support
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15. I can open a door without assistance to enter a room
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16. I can kick a ball whether it is a soccer ball or a football
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17. I can throw a netball or a basketball
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18. I can catch public transport (bus, tram or train) without support
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19. I tend to walk slowly
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20. Sometimes I may bump into things or people
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QUESTIONS ABOUT MY ENDURANCE:
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21. I can sit down for more than 30 minutes at a time
22. I can walk up more than one flight of stairs without getting puffed, wheezy or dizzy
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23. I can walk for at least 20 minutes without having a break
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24. I usually have enough energy to participate in activities most of the day
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25. List the things that may affect my endurance such as medications, heart health or asthma. Please list how we can best support you regarding this
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QUESTIONS ABOUT MY CO-ORDINATION AND FLEXIBILITY:
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26. I am quite flexible for my age
27. My co-ordination is good
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28. I can bend down and pick something up off the floor
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29. I can catch medium sized sports balls e.g. basketball, netball, football
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30. I can catch a tennis or a cricket ball
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31. I can walk upstairs without assistance
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32. I can walk to my seat in a sports stadium without assistance
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33. I can get on and off an escalator without support
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34. I can walk up and down stairs without support
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QUESTIONS ABOUT MY VISION AND HEARING:
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35. My hearing can be sensitive to cheering noises at a sporting game
36. I can get confused or irritated when there are loud noises
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37. I can see the sports players anywhere on the ground or stadium when watching a live game of sport
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38. Other things I would like you to know about my hearing or vision are e.g. need for visual aids, hearing aids etc
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QUESTIONS ABOUT MY UNDERSTANDING AND FEELINGS:
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39. I can follow instructions when I am first told
40. I move quickly from one task to another
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41. I learn best by being shown
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42. I will persist with a task until I have completed it
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43. I like things to be perfect
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44. I sometimes need to be reminded
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45. I can wait my turn when asked
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46. I am happy to try an activity that I haven't done before
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47. I can get upset easily
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48. I can become anxious at times. This may occur when e.g. there is change, need reassurance about my abilities etc
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QUESTIONS ABOUT MY COMMUNICATION:
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49. I'm usually good at looking at people when they talk to me
50. I am good at asking for help when needed
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51. I use a smart phone to
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52. I can let people know when I am feeling stressed or frustrated
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53. I can talk to people I have just met without prompting
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QUESTIONS ABOUT MY DAILY LIVING SKILLS:
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54. I can fill my water bottle and sip it throughout the day without prompting
55. I know when I am feeling hot or cold and when to put on clothes or take some off
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56. I can put my shoes on without support
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57. I sometimes need support with toileting. Please describe support required
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58. I sometimes need to go to the toilet with little warning
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59. I can find the right water temperature when running a shower or bath
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60. I sometimes need help when showering. Describe support required
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61. I have trouble falling asleep at nights
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62. I am slow to wake up and get out of bed in the morning
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63. The foods I am allergic too are
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64. Foods I do not like to eat even though I am not allergic to them
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65. I know how to cross the road safely without support
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66. I know how to use my MYKI card
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QUESTIONS ABOUT MY CO-OPERATION AND WORKING WITH OTHERS
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67. I like going out with like-minded people
68. I can greet or farewell family and friends without prompting
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69. I always try to be friendly to people I have just met
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70. I sometimes need help or encouragement to join a group. Please describe how we can support you
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71. I can become upset if others are yelling. You can calm me down by
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72. I learn best from repetition
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73. I like routine
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74. I like being around people
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75. I can feel uncomfortable in some situations. Please describe the circumstances and how we can support you best
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76. Leisure activities I like doing include e.g. walking, bowling, football etc
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