PLEASE READ CAREFULLY:

This questionnaire is designed for the carers of individuals with an intellectual disability to complete, PRIOR to the person's next appointment with Dr Pistilli.

To help Dr Pistilli prepare for their upcoming appointment, please attempt all questions.

It is important that the person completing this report (the carer) has an understanding of the referred person's living situation, supports and services involved in their care, and details relating to the reason for referral.

To assist you in completing the questionnaire, please have at hand the following information:

- List of the persons current medications, including dosages.
- Recent medical reports, (specialists, psychiatrists, etc).
- Recent medical investigations and blood results
- Recent reports from disability practitioners (psychologists, occupational, speech therapists etc.)




All submitted reports will be stored securely and confidentially, in accordance with the Health Records and Information Privacy Act 2002 (HRIP Act). They will not be shared to third parties without written consent from the patient or their legal guardian.

For support to complete this questionnaire or for all other appointment matters please contact  Mind Oasis Clinic on (02) 9011 6800


Estimated completion time:   10 minutes.