3912 – 29 Street NE Calgary, AB T1Y 6B6  Phone: 242-6672  Fax: 209-0528
www.newageservices.ca information@newageservices.ca
ATTENDING PRACTITIONER’S STATEMENT
PATIENT NAME: _______________________ _____ BIRTHDATE: ______________ PHONE: _______ ____________
ADDRESS: _______________________________CITY _______________ PROVINCE ____ POSTAL CODE__________
I authorize information regarding my ability to perform employment duties with NAS Inc. be released to them.
SIGNATURE_______________________________________________DATE________________________________
NAME OF PRACTISIONER ___________________________________ SPECIALTY___________________________
ADDRESS _________________________________________ TELEPHONE: ______________FAX_______________
New Age Services direct service staffs work alone in the community with individuals with developmental disability
who also have other challenges ranging from mild to severe. This includes medical, mobility, psychiatric,
emotional, social, safety, sexuality, legal and communication issues; aggressive and potential violent behavior.
Staff ratios vary from 1:1 to 1:4. Staffs responsibilities are to facilitate, support and participate in stimulating,
interactive client activities that develop skills and competencies to assist them. These situations are considered
high stress. In administration there is there is regular client involvement, quick thinking, multitasking, creativity
and positive interactions all in a fast paced, high stress environment.
Our policy requires staff have no impairment with regard to prescription, over the counter medication, herbal or
natural remedies or alcohol. Due to the nature of our work smelling of alcohol or other intoxicating substances
puts our clients at risk and cannot occur. Illegal substances cannot be used to work with our clientele. As our goal
is to accommodate staff in order for them to be able to continue to work for NAS Inc. we need information
regarding their abilities, treatment participation and illness limitations to do so.
YES/NO
Does the patient have a medical/psychological/physical/allergic condition that would interfere with this job?
responsibilities?
Has the patient agreed to follow through with treatment and/or assessments?
Is the condition contagious?
Is there any physical or cognitive impairment during treatment including from medication?
Is there any physical or cognitive impairment after treatment including from medication?
What is the expected time frame for recovery and return to work?
Will the symptoms re-occur?
What would be the frequency of re-occurrence?
What would 1.
be tfrequency
of re-occurance:
These movements
are required in the patient’s employment position. Can he/she do them?
YES/NO
Treatment
Timeframe
Accommodation
Timeframe
Stand for up to 6 hours
Walk for up to 6 hours
Walk on uneven surfaces
Sit for up to 6 hours
Drive for up to 6 hours
Carry up to 35lbs for 6 hours
Lift up to 35 lbs up to 8 x per day
1|P age
Assist adult standing to sit/lay
Transfer adult to sitting/standing
Physically block aggression
Kneel up to 20 x per day
Squat up to 20 x per day
Reach arms up/out up to 20 x/ day
Bend up to 20 x per day
Climb up to 20 x per day
Run up to 10 min up to 5x per day
Swim/water support for 2 hrs/day
Arm/foot/body moves for sports
Write/type daily reports
2.
These functions are required in the patient’s employment position. Can he/she do them?
YES/NO
Treatment Timeframe Accommodation
Cognitive ability to follow work rules
Maintain concentration
Able to give instruction to others
Understand/remember/carryout complex instructions
Professional coworker contact
Professional supervisor contact
Keep dependent adults/self safe
Support dependent adults medical and medication needs
Engage socially with dependent adults
Engage dependent adults intellectually
Engage dependent adults emotionally
Have professional relationships with dependent adults
Have empathetic response
Use judgment
Make simple decisions for dependent adults
Make complex decisions for dependent adults
Direct/ control/plan activities for dependent adults/staff
Work in isolation professionally
Respond clearly to crisis situations
Manage frequent high stress situations up to 6 hours/day
Cognitive ability to drive, interpret, communicate, write,
gather information professionally
Professional communication
3.
Timeframe
Comments or other information to assist us in determining how to best accommodate your patient.
PRACTITIONER SIGNATURE_______________________________________DATE___________________________
2|P age