Personal Details

Your Personal Details

Full Name inc. Title:

Preferred name:

Date of Birth:
Address:

Mobile Telephone Number:

Preferred Language:

Next of Kin Details

Name:

Address:

Home Telephone Number:

Work Telephone Number:

Mobile Telephone Number:

Relationship to you:

Emergency Contact Details - (if different from Next Of Kin)

Name:

Relationship to you:

Home Number:

Mobile Number:

GP Details

GP Name:

Surgery Name:

Surgery Address:

Telephone Number:

Out of Hours Telephone Number:

Social Worker

Name:

Address:

Telephone Number:

Out of Hours Telephone:

About You and Your Life History

About You and Your Life History

Note: Consider things such as Birth Place, Growing Up, Work, Family, Relationships, Significant Dates, Interests/Hobbies, TV Programs, Books/Papers, Food & Drink likes/Dislikes):

Medical and Medication

Medical and Medication Information

Known Allergies

Medical History

Current Types of Medication (Consideration MUST be given to the type of Medication and level of Staff Interaction as some Medication Types and Administration Methods will require 'Specialist Training')

List ALL Current Medications: (see MAR Sheet for details etc.)

Medication Dispensing:
Medication & Medical Needs

Does the Service User Self Medicate?

Are Staff Required To have involvement with Service User Medication?

What Level of Input will be required by Staff?

Does any Medication Assistance require Staff to have 'Specialist Training'?

Specialist Training Requirements:

Are there any 'Special' Training Requirements as per Local Authority?

Local Authority Requirements:

Is a MAR Chart in Place and Ready for use?

CONTACT OFFICE TO ARRANGE FOR MAR CHART BEFORE COMPLETING THIS SECTION

Difficulties taking Medication e.g. Swallowing, Spilling Liquid Meds etc?

Details of any Difficulties:

Does Management of Prescribed or Un-Prescribed Medication(s) have 'Potential' to Cause Risk?

Details of any Potential Risks:

Is All Appropriate Documentation On File? e.g. MAR Sheets, Controlled Drugs Records, Disposal Forms etc.

Any Relevant Notes or Information:

Are there any 'Controlled Drugs' on the premises?

Are they Adequately Stored?

Details of Storage Improvement Requirements:

Is a 'Consent to Treatment' Form required? (Mental Health)

COMPLETE A 'CONSENT TO TREATMENT' FORM BEFORE COMPLETING THIS SECTION

Skin Care

Skin Care and Pressure Care

Are there any Skin Care Concerns at this time?

Describe Skin Care Routine and Clearly Mark on 'Body Chart':

Skin Care Products to use:

Are there any Pressure Care issues at this time?

CLEARLY IDENTIFY ON BODY CHART

Describe in detail the Pressure Care Routine to use:

What pressure Care Aids are to be used?

Is a 'Turns Monitoring' Form Required?

Has the Turns Monitoring form been Completed and included with the Care Plan?

Sight - Hearing - Communication

Sight - Hearing - Communication

Service Users Sight is:

Does the Service User Wear Glasses?

Glasses required:

Other Relevant Information: (contact lenses etc)

Service Users Hearing is:

Is a Hearing Aid or Hearing Device Used?

Details of Devices Used by Service User:

Service Users Levels of Verbal Communication and Conversation are:

Do they Respond Well to YES / NO Type Questions?

What other types of Communication can be used? (Picture/Note Pad/Sign etc)

Existing Support

What Existing Care / Support do you Currently Receive?

Details of any Existing Care / Support you currently receive: (name of person/organisation - contact details inc address - type of Care/ Support and days/times)

Mobility and Dexterity

Mobility and Dexterity

Able to Walk Unaided?

Requires the use of the following items:

Is there a Risk relating to any of the Mobility Aids?

RISK ASSESSMENT AND MANGE,ENT PLAN COMPLETED?

Able to Go Out Alone? (If NO give details)

Will Staff be required to assist the Service User on External Activities?

Please Complete an 'EXTERNAL RISK ASSESSMENT' Form for all external activities

Has the Service User 'Fallen' in the Past 12 months?

Record Details and complete a 'Falls Risk Assessment' Form

Are you able to answer the Door to Allow Care Staff In?

Details of how Care Staff will Gain Entry to the Premises: (e.g. Key Safe, Key Holding, someone present etc)

Showering/Bathing/Grooming

Showering / Bathing / Washing / Grooming
Service User Prefers:

Service User is:

Bathing Risk Assessment Completed?

Details of Preferred Frequency & Day / Time:

Showering / Bathing Aids:

Details of Other:

Details of Preferred Toileteries:

Hair Care:

Service User is:

Hair Dresser Frequency and Details:

Facial Hair

Service User Prefers:

Details of Other:

Shaving Frequency and Details:

Details of any Other Hair Removal Requirements:

Oral Hygiene Routine

Own Teeth:

Details of Teeth:

Dentures:

Details of Dentures:

At Night, Dentures are to be:

Foot Care

Service User is:

Details of Foot Care Routines & any Specialist Treatment:

Dressing / Undressing

Dressing and Undressing Requirements

Service User is:

Details of All Assistance Required:

Continence Needs

Continence Requirements
Toileting Regime:
Toileting Aids:

Bladder Management

Service User is:

Management Aids:

Details of Incontinence:

Details of Specific Toilet Times / Routines / Aids use:

Bowel Management

Service User is:

Management Aids:

Details of Incontinence:

Details of Specific Toilet Times / Routines:

Eating and Drinking

Eating and Drinking Requirements

Are there any Enteral (PEG/NGT) Feeding Requirements?

Give detailed information as to requirements:

Prefers to have Meals in their:

Give Detail of Other:

For Eating, the Service User is:

Service User is:
Type of Diet is:

Is there a requirement for a 'Special Diet'?

Details of 'Special Diet'

Are there any foods the Service User SHOULD NOT Consume?

Give full details of food items the Service User may not consume and reasons why:

Is there a requirement for and specific Eating Aids?

Give Full Details:

For Drinking, the Service User is:

Do they have a 'Preferred' drink?

Details of Drinks:

Is there a requirement to use a 'Thickener' ?

Details of Thickener required:

Are any 'Drinking Aids' required?

Give Details of Drinking Aids:

Domestic Needs

Domestic Needs - Meals and Meal Preperation

For Preparing / Cooking / Heating Meals, the Service User is:

Are there any known Food Allergies:

Give details of foods to avoid:

Details of Preferred Meals and Times:

For preparing Drinks, the Service User is:

Details of Preferred Drinks and Times:

Domestic Needs - Housework

Will Staff be required to undertake General Cleaning duties?

Details all Cleaning duties:

Domestic Needs - Beds

Will Staff be required to make / change beds?

Details of Routine and Requirements:

Domestic Needs - Laundry

Will Staff be required to undertake Laundry duties?

Details of Routine / Detergents / Drying etc.

Domestic Needs - Shopping

Will Staff be required to undertake Shopping duties?

Is a 'Financial Record' form in place?

Details of Shopping Requirements inc. Days / Times / Locations etc:

Sleeping and Settling

Sleeping and Settling Requirements
Usual Time to Rise:
Usual Time to Bed:

Daytime Rest Routine:

Preferred Sleeping Position:

Preferences for Bed Coverings / Pillows etc.

Sleeping Aids:

Sleeping Aids Details:

Room Preferences:

Night Time Patterns:(e.g. Wanders/Talks/Shouts etc.)

Details of any Night Time Checks Required:

Finances

Finances

Does the Service User manage their own finances

Contact details for Finance Management:

Have they made any Advanced Decisions?

Contact details of responsible Person:

Have they prepared a Will?

Contact details of responsible Person:

Emotional Wellbeing

Emotional and Mental Wellbeing

Do you have any Emotional Wellbeing or Mental Health considerations?

Relevant Details:

Do identified Mental Health considerations have potential to cause a risk?

Who is at Risk?

Give Full Details:

Do identified Emotional Wellbeing considerations have potential to cause a risk?

Who is at Risk?

Give Full Details:

Has a 'Triggers and Precipitating Factors' form been completed

Is there a risk of 'Wandering'?

Is a Full Risk Assessment and Management Plan completed?

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.