This form is used to understand your health condition, functional profile and participation needs. Information is stored securely, shared only with authorised parties and used to develop an individualised support plan. You may withdraw consent at any time.
I have read and understood the above privacy statement.
Preferred name/pronouns
Name of primary assessor (if applicable)
Assessment date
Age (years)
Gender identity
Primary language for communication
Preferred communication formats (select all that apply)
Spoken language
Written text
Large print
Braille
Easy-read
Sign language video
Audio description
Real-time captioning
Other
Do you need an interpreter or communication assistant during appointments?
List every diagnosis or health condition that affects your day-to-day function, in order of impact.
Health conditions
Use the 3-point health status scale: Improving, Stable, and Declining.
Condition / diagnosis | ICD-11 code (if known) | Date of onset / diagnosis | Status | Managing clinician / facility | |
|---|---|---|---|---|---|
Example: Bilateral sensorineural hearing loss | AB40.0 | 8/15/2015 | Stable | Dr. S. Lee, Audiology | |
Are any of your conditions episodic or unpredictable in nature?
Current medications/treatments
Medication / therapy name | Dose & frequency | Prescribing clinician | Causes side-effects impacting function? | Describe side-effects (if any) | |
|---|---|---|---|---|---|
Metformin 500 mg | Twice daily | Dr. A. Rahman | |||
Non-pharmacological therapies currently used
Physiotherapy
Occupational therapy
Speech & language therapy
Counselling/psychotherapy
Acupuncture
Traditional medicine
Religious or spiritual healing
Exercise programme
Dietary programme
Other
Are you waiting for, or currently undergoing, any surgical or interventional procedures?
Rate the level of impairment for each function over the past 30 days. 0 = none, 5 = complete loss/cannot do.
Impairment rating
0 | 1 | 2 | 3 | 4 | 5 | |
|---|---|---|---|---|---|---|
Seeing (with best correction) | ||||||
Hearing (with best aid) | ||||||
Speech articulation | ||||||
Mobility – walking 100 m | ||||||
Mobility – climbing one flight of stairs | ||||||
Hand & finger use – grasp/manipulate | ||||||
Bladder control | ||||||
Bowel control | ||||||
Sensation – touch/pain | ||||||
Intellectual function | ||||||
Emotional regulation | ||||||
Energy/endurance |
Do you experience chronic pain?
Rate average pain intensity in the last week (0 = no pain, 10 = worst pain imaginable)
0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
|---|---|---|---|---|---|---|---|---|---|---|---|
At rest | |||||||||||
During activity |
Rate difficulty without assistance (1 = none, 5 = extreme/cannot)
None | Mild | Moderate | Severe | Cannot | |
|---|---|---|---|---|---|
Getting dressed | |||||
Bathing/toileting | |||||
Preparing meals | |||||
Eating/drinking | |||||
Doing housework | |||||
Managing money & paperwork | |||||
Moving around inside home | |||||
Going outside alone | |||||
Using public transport | |||||
Working in a job | |||||
Attending school/training | |||||
Participating in social events | |||||
Making friends/relationships | |||||
Caring for others |
Are there specific activities you avoid because of environmental barriers?
Which assistive devices do you currently use? (select all)
Wheelchair (manual)
Wheelchair (power)
Walker/rollator
White cane/smart cane
Hearing aids
Cochlear implant processor
Communication board/book
Speech-generating device
Text-to-speech app
Screen-reader software
Braille display
Magnifier/CCTV
Prosthesis (upper limb)
Prosthesis (lower limb)
Orthosis/splint
Compression garments
Continence products
Other
Is any device you need unavailable to you due to cost, supply or policy?
Do you need training or ongoing support to use your assistive technology effectively?
Primary living setting
Urban
Rural
Remote/isolated
Refugee camp
Institution
Homeless/temporary
Other
Dwelling type
Single-storey house
Multi-storey house
Apartment (with lift)
Apartment (no lift)
Informal housing
Shared accommodation
Independent living unit
Other
Is your home fully accessible for your needs?
Highest level of education completed
No formal schooling
Primary incomplete
Primary complete
Lower secondary
Upper secondary
Post-secondary certificate
Bachelor degree
Master/Doctorate
Current employment status
Full-time paid
Part-time paid
Self-employed
Informal/gig
Supported employment
Unemployed (seeking)
Unemployed (not seeking)
Student
Retired
Homemaker
Unable to work due to disability
Other
Do you experience discrimination or stigma related to your disability?
Think about the next 12 months. What matters most to you?
Rank the following life areas by importance to you (drag to order; 1 = highest)
Health & wellbeing | |
Education & learning | |
Employment & livelihood | |
Independent living | |
Relationships & intimacy | |
Community participation | |
Hobbies & leisure | |
Spiritual fulfilment |
Describe one goal you want to achieve and what success looks like for you.
Would you like a copy of the final assessment report in an alternative format?
Do you have an unpaid family member or friend who regularly helps you?
If you need help, can you get it within 15 minutes?
Always
Usually
Sometimes
Rarely
Never
Are you a caregiver for someone else (child, elder, sibling)?
In the past 2 weeks, how often have you been bothered by the following?
Not at all | Several days | More than half the days | Nearly every day | |
|---|---|---|---|---|
Little interest or pleasure in doing things | ||||
Feeling down, depressed or hopeless | ||||
Feeling nervous, anxious or on edge | ||||
Not being able to stop or control worrying |
Overall, how would you rate your current mental wellbeing?
Excellent
Good
Fair
Poor
Decline to answer
Have you ever thought about harming yourself?
Which of the following services have you used in the past 12 months?
Primary care/family doctor
Specialist medical
Allied health (PT, OT, ST)
Mental health counselling
Social work/case management
Disability benefits/pension
Vocational rehabilitation
Community rehabilitation
Residential respite
Tele-rehabilitation
None
Other
Have you been denied any service that you believe you need?
How long does it take you to reach your usual health-care provider?
Less than 30 min
30–60 min
1–2 h
More than 2 h
Unable to travel/no provider
Do you have access to financial assistance for disability-related costs?
Describe a typical day from waking up to going to sleep, highlighting when you need help.
List any triggers that worsen your symptoms and any strategies you use to manage them.
Tell us about your strengths, talents or hobbies that bring you joy.
Do you have an emergency care plan (e.g., seizures, severe allergic reaction)?
Emergency contact name
Emergency contact phone/relay service
Special instructions for responders (e.g., communication method, positioning, medication contraindications)
I confirm that the information provided is accurate to the best of my knowledge. I understand that this assessment is one step toward identifying supports and that I can request updates as my situation changes.
Would you like a support person, advocate or interpreter to co-sign?
Signature of person being assessed (or legal representative)
Analysis for Disability Medical Assessment Form
Important Note: This analysis provides strategic insights to help you get the most from your form's submission data for powerful follow-up actions and better outcomes. Please remove this content before publishing the form to the public.
This Comprehensive Disability Medical Assessment Form is a best-practice exemplar of universally-designed, ICF-aligned data collection. By embedding optional vs. mandatory discipline, the form balances rich clinical detail with user autonomy, a critical factor in disability contexts where excessive compulsory fields can trigger form abandonment. The progressive-disclosure pattern (follow-ups only appear when relevant) reduces cognitive load, while the matrix-style ratings standardise data for downstream analytics, funding decisions, and international comparability. The explicit consent & privacy section at the start satisfies GDPR, HIPAA, and many national disability-information acts, fostering trust and legal compliance.
Structurally, the form mirrors the biopsychosocial model: body functions, activities, participation, environment, and personal factors are all captured, ensuring no domain is overlooked. Built-in accessibility affordances—Braille, Easy-read, sign-language video, real-time captioning—model the inclusion it seeks to measure. The ranking of life-area goals and open-text narratives counterbalance quantitative scales, giving respondents a voice and yielding qualitative data essential for individualised support plans.
Purpose: Establishes informed, freely-given consent for data processing—a legal prerequisite under most data-protection statutes.
Design Strengths: Placed at the very beginning, the checkbox enforces stop-point logic: users cannot proceed until consent is signalled, eliminating incomplete submissions lacking legal cover. The adjacent paragraph clarifies scope, retention, and withdrawal rights in plain language, reducing later disputes.
Data-Collection Implications: Because consent is timestamped, audit trails are defensible if regulators or participants query data use. The single mandatory checkbox keeps the barrier low while satisfying due-process requirements.
User-Experience Considerations: One-click affirmation is quick; pairing it with plain-language notice respects varying health-literacy levels common in disability populations.
Purpose: Anchors the functional snapshot in time, critical for longitudinal tracking and eligibility windows in many benefit schemes.
Design Strengths: A native HTML5 date-picker prevents format ambiguity (no 01/02 vs 02/01 confusion) and auto-validates realistic ranges (e.g., cannot be future-dated beyond system clock).
Data-Collection Implications: Accurate dating enables cohort studies, outcome measurement after interventions, and safeguards against duplicate assessments within prohibited timeframes.
User-Experience Considerations: Mandatory status is justified; without a date, the entire assessment lacks temporal context, rendering data unusable for funding or clinical decisions.
Purpose: Age stratifies functional expectations (e.g., 5-year-old vs 85-year-old gait norms) and determines programme eligibility (children’s vs adult services).
Design Strengths: Numeric entry accepts decimals for infants (0.25 yrs) and prevents alphabetic typos through input masking.
Data-Collection Implications: Age is a core covariate in virtually every disability-analytics model; missing data would impair actuarial tables and policy planning.
User-Experience Considerations: One field, high value; keeping it mandatory avoids downstream data-imputation errors that could misclassify support needs.
Purpose: Person-centred planning requires at least one self-articulated goal to drive tailored interventions and measure success.
Design Strengths: Open-text elicits idiosyncratic aspirations (e.g., "I want to dance at my daughter’s wedding") that tick-box items cannot capture. The 12-month horizon keeps goals concrete.
Data-Collection Implications: Qualitative goals become KPIs in support-plan evaluations; without them, services risk being generic rather than individualised.
User-Experience Considerations: Making this mandatory signals respect for user agency; however, the form should preface with an example to reduce writer’s-block abandonment.
Purpose: Ensures responder can reach a trusted person during medical crises, fulfilling duty-of-care obligations.
Design Strengths: Splitting name and phone allows validation (phone regex) and prevents comma-separated parsing errors. Accepting relay-service numbers accommodates Deaf users.
Data-Collection Implications: Accurate contacts reduce adverse-event liability for providers and speed emergency interventions.
User-Experience Considerations: Mandatory status is ethically non-negotiable; an uncontactable patient in crisis endangers life.
Purpose: Provides attestation that data are accurate, creating legal validity for funding, insurance, or court proceedings.
Design Strengths: Digital signature component captures timestamped hash, ensuring non-repudiation. Co-signatory option includes advocates, respecting supported-decision-making frameworks.
Data-Collection Implications: Signed assessments are audit-proof; missing signatures are routinely rejected by insurers and government funders.
User-Experience Considerations: Mandatory signature is standard legal practice; offering alternative formats (e.g., click-to-sign plus audio confirmation) can aid users with fine-motor limitations.
Mandatory Question Analysis for Disability Medical Assessment Form
Important Note: This analysis provides strategic insights to help you get the most from your form's submission data for powerful follow-up actions and better outcomes. Please remove this content before publishing the form to the public.
Question: I have read and understood the above privacy statement.
Justification: Without explicit consent, the form cannot legally process special-category health data. This checkbox ensures GDPR Article 9 and equivalent disability-data protections are satisfied, protecting both user and organisation from unlawful-processing claims.
Question: Assessment date
Justification: A dated assessment is essential for eligibility windows, benefit recency rules, and longitudinal outcome tracking. It prevents stale data from being used in life-affecting decisions and anchors all follow-up timelines.
Question: Age (years)
Justification: Age is a deterministic variable for norm-referenced functional scores and programme eligibility (e.g., paediatric vs adult services). Omitting it would invalidate actuarial risk models and contravene many funding-scheme data standards.
Question: Describe one goal you want to achieve and what success looks like for you.
Justification: Person-centred planning regulations (e.g., NDIS, ADP) require at least one self-directed goal to authorise individualised budgets. A mandatory narrative ensures services address actual aspirations rather than clinician-assumed priorities.
Question: Emergency contact name
Justification: In medical emergencies, responders must reach someone who knows the user’s baseline condition and can provide surrogate history. Mandatory capture fulfils clinical-governance duty-of-care standards.
Question: Emergency contact phone/relay service
Justification: A name without a contact pathway is useless in crisis. Valid phone numbers (including relay services for Deaf users) are life-critical data, hence mandatory.
Question: Signature of person being assessed (or legal representative)
Justification: Digital or wet signatures create legal attestation required by insurers, courts, and funders. Without a signature, the document lacks evidentiary weight and can be repudiated, invalidating benefit claims.
Question: Date (Review section)
Justification: Paired with the signature, the date establishes the moment of consent, satisfying statutory limitation periods and enabling chronological audit trails for compliance reviews.
The form adopts a minimal-mandatory philosophy: only eight fields out of 100+ are compulsory. This strategy maximises form-completion rates while safeguarding legal and clinical non-negotiables (consent, temporal context, individualised goals, emergency safety, and legal attestation). To further optimise, consider conditional mandatoriness: if a user indicates they have an emergency plan, require the upload only when ‘Yes’ is selected. Additionally, provide real-time micro-copy (“Why we need this”) beside each mandatory label to pre-empt user frustration. Finally, allow save-and-resume functionality so that respondents who need to gather emergency-contact details are not forced to abandon the entire session.
Audit the current ratio periodically; if analytics show high abandonment at the goal-description field, introduce an optional example tooltip or voice-to-text helper rather than making it optional—because individualised funding hinges on this narrative. Conversely, monitor emergency-contact duplication: if many users type identical contacts, consider a checkbox to copy from an earlier section, reducing re-keying while preserving mandatory status.