Carer Visa Assessment Form ( Bupa Application)

Examinee / Resident Details

First Name

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Last Name

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Your E-mail Address

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Sex

Male

Female

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Date of Birth

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Date of arrival in Australia

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Daytime telephone number

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Mobile phone number

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Address...

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City

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Zipcode

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Have you undergone a previous assessment/examination for a Carer visa application?

Yes

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Date

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About the person you are asking to come to, or remain in Australia, as a carer

Personal details of the person

First Name

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Last Name

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Date of Birth

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What is your relationship with this person?

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Please name all persons who will be coming with the main carer (i.e. other family members migrating with them)

Name

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Relationship

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Has this person already lodged the carer visa application with Department of Home Affairs?

Yes

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Receipt number

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Date

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Your current situation

What is your current situtation？

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What are your main medical conditions that result in your need for extra assistance?

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Who currently helps you with activities requiring extra assistance?

Name

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Age

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Relationship

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Do you require assistance in the following areas?

Bathing and showering (e.g. washing, help in and out of the bath or shower)

Toileting (e.g. help getting on or off the toilet, cleaning up incontinence

Dressing, undressing and grooming (e.g. haircare, shaving, dental care, help with zips or buttons, help with drawers/wardrobes, fitting prosthetics

Eating (e.g. assisting with feeding and cooking, holding straws, cutting up food, preparation of special diet)

Mobility (e.g. walking, pushing the wheelchair, assisting with stairs, moving in and out of bed or turning)

Special exercise therapy

Transportation because of disability (e.g. to physiotherapy, to medical appointments)

Preparing or supervising medication (e.g. sterilising equipment, changing dressings, care of prosthetics)

Field is required!

Time taken each day to provide the assistance in Bathing and showering

Less than 30 minutes

30-60 minutes

60-120 minutes

More than 120 minutes

Field is required!

Time taken each day to provide the assistance in Toileting

Less than 30 minutes

30-60 minutes

60-120 minutes

More than 120 minutes

Field is required!

Time taken each day to provide the assistance in Dressing, undressing and grooming

Less than 30 minutes

30-60 minutes

60-120 minutes

More than 120 minutes

Field is required!

Time taken each day to provide the assistance in Eating

Less than 30 minutes

30-60 minutes

60-120 minutes

More than 120 minutes

Field is required!

Time taken each day to provide the assistance in Mobility

Less than 30 minutes

30-60 minutes

60-120 minutes

More than 120 minutes

Field is required!

Time taken each day to provide the assistance in Special exercise therapy

Less than 30 minutes

30-60 minutes

60-120 minutes

More than 120 minutes

Field is required!

Time taken each day to provide the assistance in Transportation because of disability

Less than 30 minutes

30-60 minutes

60-120 minutes

More than 120 minutes

Field is required!

Time taken each day to provide the assistance in Preparing or supervising medication

Less than 30 minutes

30-60 minutes

60-120 minutes

More than 120 minutes

Field is required!

Is constant supervision required in the following areas?

Monitoring/supervision – during the night (e.g. administering timed medications, ensuring you do not wander off)

Monitoring/supervision – during the day (e.g. ensuring that you do not wander off, ensuring that gas/stove/taps are turned off, preventing other unsafe behaviour)

Field is required!

Time taken each day to provide the assistance in Monitoring/supervision – during the nigh

Less than 30 minutes

30-60 minutes

60-120 minutes

More than 120 minutes

Field is required!

Time taken each day to provide the assistance in Monitoring/supervision – during the day

Less than 30 minutes

30-60 minutes

60-120 minutes

More than 120 minutes

Field is required!

Ask us other assistance or supervision required...

Field is required!

Time taken each day to provide this assistance

Less than 30 minutes

30-60 minutes

60-120 minutes

More than 120 minutes

Field is required!

What are your current assistance arrangements?

Who looks after you? How often? For what length of time?

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Who is the doctor you usually see about your illness/disabilities?

Name of doctor

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Address of doctor

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Contact Telephone

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Has a specialist or another doctor/specialist treated you for these illnesses/disabilities?

Yes

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Name of specialist/consultant

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Address of specialist/consultant

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Date of last visit

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Conditions for which you were treated

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If you need to give more information, please use the space.

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Is there anybody else who could tell us about any of your illnesses/disabilities?

(e.g. Psychologist, physiotherapist, counsellor, community worker)

Yes

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Name of other practitioner

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Profession

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Address of person

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Contact Telephone

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If you need to give more information, please use the space.

Field is required!

Have you ever been admitted to hospital for treatment of these illnesses/disabilities?

Yes

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Date of last admission

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Discharge date of last admission

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Name of hospital

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Reason for admission (e.g. operation, investigation, treatment)

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Number of hospital admissions in the last five years

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If you need to give more information, please use the space.

Field is required!

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Please follow the link below for FREE INITIAL CONSULTATION

If you want to know more about Australian visa, you can get in touch with us and we will be happy to help you!

Address: 6/13 Bridge St Epping NSW 2121

Tel: 02-8203 2999

Facebook: Aussie Immigration Services

Carer Visa Assessment Form ( Bupa Application)

Examinee / Resident Details

About the person you are asking to come to, or remain in Australia, as a carer

Your current situation

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