The patient’s past medical and surgical history should be obtained and recorded on page 1 of the PAF. Completed sample of Patient Assessment Form Page 1 of 4 The Patient Assessment Form (PAF) should be completed by the health care professional on the patient’s admission before a course of treatment is given. The physical observations, admission screening and presenting problems or diagnoses should be completed and recorded on page 1 of the PAF.

Page 2 of 4 It is possible to reduce repetitious questioning for the patient and health care professionals by recording this information on a Birth History Record. It is possible to reduce repetitious questioning for the patient and health care professionals by recording this information on the Immunisation and Infectious Disease Record.

Page 3 of 4 All female parents who may be pregnant, must be identified prior to surgery or other high risk procedures. Although very low, there is a theoretical risk of CJD/vCJD transmission from asymptomatic cases through the reuse of surgical instruments or endoscopes. As the consequences would be very serious additional screening steps are required, in certain circumstances, to identify individuals who may be at increased risk of asymptomatic disease. Identification of these individuals should not alter their management but does alter the way we re-process instruments used from them. There are two groups of people to identify. Question 1. A number of individuals have been informed by Public Health that they are at an increased risk and you are requested to ask for this specifically in all cases. Question 2. Where children are having surgery specifically on high risk tissues, additional questions are required to identify those with a higher (although still low) risk of asymptomatic vCJD. Additional procedures would be necessary regarding the re- processing of the instruments. If positive answers are given to the screening questions further investigations are required. The patient is physically examined and findings should be recorded on page 3 and 4 of the PAF. Additional continuation sheets may be used as required.

Page 4 of 4 The overall assessment of the patient, the management plan and any other investigations required should be recorded on page 4 of the PAF. The parent’s and patient’s understanding of reasons for the treatment should be obtained and recorded on page 4 of the PAF. The patient and their parents may be given written information about their medical condition or treatment. The completed PAF must include specific requirements for the discharge of the patient.