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Austr.llian CO\ern111ent
J>t p:artnM.·111of llumau Stn ite$
Carer Payment and/or Carer Allowance •
Medical Report (SA332a)
centre/ink for a person - 16 years or over

-
If completing fonm by hand: • Print clearly using a black pen only • Print one character in each box • Do not use correction fluid or tape
• Use BLOCK LETTERS • Print in all appropriate boxes
---------
Person being cared for details Name IS I\\ IAl~ lr l@ t;lv lE IDI IA ILl:cl I I I II I I

I I I I I I I I I I I I I I I I I I I I I I

rn [Qlil
Day Month Vear

Dateofbirth lil olo l~ I

Centrelink or Department lib JqIslu l(ii1ilild
Customer (carer) details
Your details do not need to be
Name i\- l~ bl A I\-\J IA:l ~lµ l~ IAliSJ I I J J 1 111 11
completed if you are only testing I I I I I I I I I I I I I I I I I I I I I I I I
eligibility for a Special Disability Trust
Address l½~ l 1 led IQ R.l~ loh l lw lE l s fr l EIIZINI 11 111

I~,I gu l ui vi I I I I I I I I I II
I I II I
I I~ @GI'I I5k} c,J NIE l s l I I I
Day Month Vear
t
I I I PoS COde 12 l1f9 st
@I] I\ jq I z.141
Date of birth
Your Centrelink Reference Number I1) o lqI11
g¼IJIiJs:·l1<)
Your contact details If you provide an email address or mobile phone number, you may receive electronic
messages (SMS or email) from us. To read the Terms and Conditions, go to
huma~ervices.gov.au/em

Daytime number Io ly l \ li n 131b l 1 rs :l:1I

Email ls. l~ lo. l~ I\ f ld I qj \ I "i l~ I ~1¤1 ~ I o l-t lMI d ·1111, lc lo ld
II I I I I I I I I I I I II I I I II III I I

This report must be completed by one of the following health professionals who are currently involved in the
treatment of this person:
• a legally qualified medical practitioner • a physiotherapist • a member of an Aged Care Assessment Team
• a registered nurse • an occupational therapist • an Aboriginal health worker (in a geographically remote area).

Instructions for the customer (carer)

0 Complete your details above.

f) Make an appointment with a Treating Health Professional. When you make your appointment, please let the receptionist know you
will need this report completed.
The time taken to complete this report may be claimed by the treating doctor under a Medicare item when included as part of a consultation.
You may only be able to claim the consultation fee for other health professionals under private health insurance. If the Treating Health
Professional does not bulkbill, your consultation fee may be more because of the extra time taken to complete the report.

0 Assessment is for: Carer Allowance D Carer Payment and CarerAllowance D Special Disability Trust (beneficiary status) D

I
111 11111111IIIIIIIII llllllll llll 1111111111111111111111111111 111111
CLK0SA332a 1609

SA332(3).1 809 1 of 7
 ~------------
•
-- -

0 Privacy and your personal information

Your personal information is protected by law (including the Privacy Act 1988) and is collected by the Australian Government Department of
Human Services for the assessment and administration of payments and services. This information is required to process your application
or claim.
Your information may be used by the department. or given to other parties where you have agreed to that, or where 1t is required or
authorised by law (including for the purpose of research or conducting investigations).
You can get more information about the way in which the department will manage your personal information, including our privacy policy, at
humanservices.gov.au/privacy

0 Authorisation for release of medical details by the person being cared for.
• I give permission for relevant medical details and clinical notes about me to be released to the Australian Government Department of
Human Services.
• I understand that the report will be used to assist in assessing a claim for Carer Payment and/or Carer Allowance for current and future
carers, OR establishing eligibility for a Special Disability Trust (Son and may need to be released to that person(sJ by the Australian
Government Department of Human Services.
Date
Day Month Year

ru1l lif ol 2\J

0 Give this report to the doctor or Treating Health Professional of the person being cared for to complete.

i\AlJ:>to) '8t~l 2of7

 Instructions for · This report is based on tile Adult Disability Assessment Tool
(ADAT). The ADAT is used only for the purpose of assessing
the Treating Health Professional . eligibility for Carer Payment (adult), Carer Allowance (adult)
' and Special Disability Trusts. Its purpose is to measure
This report may be used to decide ellglblllty for: 1 the level of care needed by an adult because of his or

• Carer Allowance - an income supplement for people who
provide additional daily care and attention for an adult or child
with a disability or a medical condition, or an adult who is frail
aged. It can be paid in addition to wages, or another income
support payment.
, her disability, and is designed to provide access to Carer
i Payment, Carer Allowance and Special Disability Trust for
I carers of people with similar levels of disability, even where
: the cause and type of disability differ. The ADAT measures
1 the amount of help required to undertake activities of daily

Carer Allowance is not taxable or assets tested. Carer Allowance
is income tested.
• Carer Payment - is an income support payment paid to carers
who, because of the demands of their caring role, are unable to
support themselves through substantial paid employment.
• Special Disability Trust beneficiary status - a trust established
solely in order to provide for the current and future care and
accommodation needs of a person with a severe disability.
[ living such as mobility, communication, hygiene, eating and
j a range of cognitive and behavioural areas. This may include
; supervising and prompting the care receiver to undertake
1 these daily activities.
1 Does the person being cared for have physical, intellectual or
psychiatric disabilities?

Payment for your report physical _gJ'

We have asked the carer to let you know at the time of making intellectual
their appointment that they require you to complete this report for psychiatric 0
your patient. This is to make sure that you have sufficient time for
the examination.
2 Please advise the disability and/or medical condition(s) of the
The time taken to complete the medical report may be claimed person being cared for.
under a Medicare item when included as part of a consultation.
Completing this report
In this report you will be asked to provide details of the person 's
medical condition(s). Please complete all the required questions in
this report. If you have any questions about this report, you can call
us on 132 717.
Returning this report to us
You can give this report and any attachments to the person providing
care or you can return this report directly to the Department of II II II IIIIIIII
Human Services.
Thank you for your assistance
II II II IIIIIIII
II II II IIIIII I
II II II IIIIII I
II II II IIIIII I
II III II I IIIIII I
3 What date did the disability or medical condition begin?
Day Maoth Year

[DE [[ID lil4JI rI\I

4 Please read this before answering the question.
Help includes physical assistance, supervision and prompting. I
Routin~ ~erson~I activities _include eating, dressing and ,
ma1ntammg hygiene or mob1l1ty. Do not include tasks such as
housekeeping, gardening, shopping, etc. 1
1
Does the person require help on a daily basisb~~;u;~;i~- '
disability and/or medical condition(s) to carry out routine
personal activities OR because they may be at risk to
themselves or to others?
No 0
Yes ~
SA332ta) 1809
3of7
5 Is the carer claiming Carer Payment? 11 Please provide the name and contact details of tl'le legally
qualified Medical Practitioner who can certify this oers0n M<; !l
No D Goto7
Yes lfk Go to next question
terminal condition.
Name ----·--

6 Is this care required for a significant period each day (at least
the equivalent of a normal working day)? !~ :~:I1~1
i _ --
Y::g0 1 I I ! I I I I ! I !_- r .
NotSure
: I I I I I I 1 I I j -

Comments Professional qualifications

I I I I I I I I : i T~--
IIIII : I ! 1I I I I I I ! I : -1 -,
1 ,

I IIIiII:IIIII
I I I I I I I I I I I In·~
I i \I\IIIIi III I L....LI1_L_ J J
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IIIIIIIIIIII I
1
Phone number

', I I I I I I I I I I I I I I I IIII IIIIII

'. I I I I I I I I I I I I I I I You do not have to complete any more medical details about
th is person.
16
7 Which best describes the person's disability/medical condition:
Terminal D Go to next question 12 Please read this before answering the following questions.
Permanent Go to 9 Personal activities for daily living-This is an assessment
Temporary O Go to 10 of personal activities of daily living. For each function, please
indicate which best describes the person receiving the care.
The information under each function should be used as a
8 Is the person expected to live more than 3 months?
record of what the person does, NOT a record of what the
No (A) D Go to 11 person could do.
Yes (8) D Go to 12 The main aim is to establish the degree of Independence
from any help, physical or verbal, however minor and for
whatever reason.
9 Is the person's overall condition likely to: A person's performance should be established using the best
Improve (C) D Go to 12 available evidence. Asking the person, friends/relatives ancl I
, nurses will be the usual source, but direct observation and i
Nol Improve (D) Go to 12
common sense are also important. However, direct testing Is '
not needed. I
10 For how long do you expect this person's condition to continue? Usually the performance over the preceding 24- 48 hours is
D
Less than 6 months (E) Go to 12 I important, but occasionally longer periods will be relevant. j

Between 6 and 12 months (F) D Go to 12

12 months or more (G) D
I Middle categories imply that the person supplies more than
50 per cent of the effort.
Go to 12 Use of aids to be independent is allowed.
Note: If the person needs to be supervised or prompted
I to perform certain tasks because of their disability and/or
medical condition(s) they are considered to be 'dependent'
or 'needing help' depending on the level of assistance they
require for the task. This may Include people with mental
I illness, acquired brain Impairment or intellectual disability,

SA332(a) 1809 4 of 7
13 It is in the person's best interests that ALL parts of 7 Mobility
question 13 (1-10) are answered. Refers to mobility about house or indoors. May use aid. If in
wheelchair. must negotiate corners/doors unaided. Help = by
Day to day needs-for each function, please lick the box one untrained person. including supervision . moral support.
which best describes the person receiving care:
Im mobile (a) D
Bowels Wheelchair independent, including corners etc. (b)
Assess preceding week. If needs enema, then incontinent. (i.e. uses wheelchair without assistance)
Incontinent (or needs to be given enema) (a) Walks with help of one person (verbal or physical) (c) D
Occasional accident (once a week) (b) Independent (dl ~ -
Continent (c)
8 Dressing
Should be able to select and put on all clothes, which may
2 Bladder be adapted. Half = requires help with buttons. zips etc. but
Assess preceding week. Occasional =less than once a day. can put on some garments alone.
Acatheterised person who can completely manage the
catheter alone is registered as 'continent'.
Dependent (a) D
Incontinent or catheterised and unable to manage (a) Needs help but can do about half unaided (b) '~
Occasional accident (once a week) (b) Independent (including buttons, zips, laces etc.) (c) D
Continent (c)
9 Stairs
To be independent, must be able to carry any walking aid
3 Grooming
used.
Assess preceding 24-48 hours. Refers to personal hygiene:
Cleaning teeth , fitting false teeth, doing hair, shaving, Unable (a) D
washing face. Implements can be provided by helper. Needs help (verbal, physical , carrying aid) (b) D
Needs help with personal care: Face, hair, teeth (a) D Independent up and down (c) pa
Independent (implements provided) (b)
10 Bathing
4 Toilet use Usually the most ditticult activity.
Should be able to reach toileVcommode, undress sufficiently, Bath: Independent = must get in and out unsupervised and
clean self, dress and leave. wash self.
=
With help can wipe self, and can do some other of the Shower: Independent = unsupervised/unaided .
above. Dependent (a) D
Dependent (a) Independent (b) 1¼!'
Needs some help but can do some things alone (b)
Independent (on and off, wiping, dressing) (c)

5 Feeding
Able to eat any normal food (not only soft food). Food cooked
and served by others, but not cut up. Help =food cut up,
person feeds self.
Unable (a) D
Needs help in cutting, spreading butter etc. (b) D
Independent (food provided within reach) (c)

6 Transfer
=
From bed to chair and back. Unable no sitting balance
=
(unable to slO, 2 people to lift. Major help 1 strong/skilled
or 2 normal people. Can sit up.
=
Minor help 1 person easily, or needs any supervision for
safety.
Unable - no sitting balance (a)
Major help (physical, 1 or 2 people), can sit (b)
Minor help (verbal or physical) (c)
Independent (d) ·~

SA~321n) 1809
5 of 7
14 Cognitive function 16 Release of medical infonnation about the person being
In your opinion, is the person cognitively impaired? cared for

No D Goto 15 1
The Freedom ~f Information Act 1982 allows for the disclosure
of medical or psychiatric information directly to the person
Yes~ I requiring care. If there is any information in your report which,
I if released to the person, may harm his or her physical or mental I
2 This is an assessment of cognitive function. well-being, please identify it and briefly state below why it
Ask the person receiving the care for the following should not be released directly to this person. Similarly, please I
information: I specify any other special circumstances which should be taken
into account when deciding on the release of your report. ,
Please answer all parts of the Abbreviated Mental Test.
Memory phrase may be repeated up to 3 times to make sure Is there any information in this report which, if released , might
the person has heard it correctly. All other questions may only • be prejudicial the person's physical or mental well-being?
I
i
be asked once, without further prompting.
No Go to next question
The Abbreviated Mental Test (AMT) Correc/4correct Yes D Identify the information and state why it should not
• Time of day (to the nearest hour) (a) [{] D be released.
Memory phrase
Repeat this phrase after me and remembe~r
II IIII
it for later - 42 West Street
• Name of institution or suburb where
I I III
the person lives (b) II I I I
• Recognition of 2 persons in the room
(doctor, nurse, carer etc.) (c) II
• Date of birth (day, month, year) (d) · D ./f II
• Name of present Prime Minister of D E( I I I
I I
• ~~:~:~:~:~ards from 20 to 1 (D ~- DD
• Ask the person to repeat the 2'.J
Memory phrase (g)
I I
3 Unable to administer Abbreviated Mental Test (AMT - 7)?
No 0
Yes D • Person unable to communicate (a) D I I
• Person refused to participate (b) D I I
15 Behaviour-for each statement, please tick the box which best I I I
describes the person's usual state.
Does the person: I I III I
1 Show signs of depression? ,.,.q,1 } II I IIIII
Sometimes (b) 0 f II IIII III I
D
III IIII I I
Most of the time (c)

Never(a) D -
011
2 Show signs of memory loss?

Sometimes (b)
III III I I I
3
Most of the time (c) D IIII I II I
Withdraw from social contact? Never (a)
D r===r=r==r==r=lr==rl~
l I~I
Sometimes (b)
D III I I I
4
Most of the time (c)
Display aggression towards self or others? Never (a)
FFT1=r==;=I=;=,Il=n=I~I~=¾=!=II
Sometimes (b)
D
II III I I II
5 Display disinhibited behaviour?
Often (c)
IIIII I I III
Never (a)
Sometimes (b) IIIII I I III
Often (c) Please r~turn this report directly to usatter-
c~mpletmg your details at question 19.
SA332(a) 1809
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17 :r----·----··- - ~-·---·-- --------~
Confidentiality of informationThe personal information Details of the Health Professional completing this report
l that is provided to you for the purpose of this report Please print in BLOCKLITTERS or use stamp.
; must be kept confidential under section 202 of the Name
l Social Security (Administration) Act 1999. It cannot be
: disclosed to anyone else unless authorised by law.
; There are penalties for offences against section 202 of the KSId m5lc!ill
IJ> leJ ii IAl-&A-ltl
!Social Security (Administration) Act 1999.
I~ 11 11111 1111 1 1 I]
18 You need to read this I_ I I I I I I I I I I I I I I~
Privacy and your personal information
Your personal information is protected by law (including
IIIIIIIIIIIIIIIII
Professional qualifications
the Privacy Act 1988) and is collected by the Australian
Government Department of Human Services for the
assessment and administration of payments and services.
U:, RlAlcJfI I I I I I I I I I I I
Your information may be used by the department, or given IIIIIIIIIIIIIIIII
to other parties where you have agreed to that, or where it
is required or authorised by law (including for the purpose of
research or conducting investigations).
IIIIIIIIIIIIIIIII
You can get more information about the way in which the
department will manage your personal information, including
IIIIIIIIIIIIIIIII
Address
our privacy policy, at humanservices.gov.au/privacy

ti'·1
ti;1 Stamp (if applicable)

t1
i
I.;
Dr eafak Gl:Jkto~an, FRACP
Suite 4211, Level 2
Ii
I 834 P\ttwater Rd
11
q Cea Why NSW 2099
,,li Phone~90e, 6622
:1
'I
Pto"'®I' no: 204557FY
I~
'

,j
Returning this report
You can give this report and any attachments to the person
providing care or you can return this report directly to us.
However, if you answered 'Yes' at question 16, please make
sure to return this report directly to:
Department of Human Services
Carer Services
µ
;, PO Box 7805
t CANBERRA BC ACT 2610
SA332(a).1809
7 of 7