EmailMeForm
Initial Health Needs & History Information
The more information you are able to provide, the quicker the application process will be. We ask these questions because we need the information in order to ensure that we are able to meet the needs of the individual.
Name
First
Last
Health History
Please give a brief outline of health history:
*
Current State of Health
Please give a brief explanation of current health needs:
*
1. Does the applicant have a diagnosis of Dementia?
*
Please select
Yes
No
2. If yes, is Dementia the primary need of the applicant?
Please select
Yes
No
3. Has the applicant ever had any infectious diseases? (for example MRSA, Clostridium Difficile)
If yes, please give details if possible.
*
Please select
Yes
No
4. Has the applicant had the Pneumococcal Septicaemia Vaccine? This is offered to all adults over the age of 70.
*
Please select
Yes
No
Unsure
5. Has the applicant had Covid-19?
*
Please select
Yes
No
6. Has the applicant had the Covid-19 vaccine?
If yes please give dates below.
*
Please select
Yes
No
Date of 1st dose
DD
/
MM
/
YYYY
Date of 2nd dose
DD
/
MM
/
YYYY
Date of booster dose
DD
/
MM
/
YYYY
Date of second booster dose
DD
/
MM
/
YYYY
Date of third booster dose
DD
/
MM
/
YYYY
7. Has the applicant had the influenza vaccine?
*
Please select
Yes
No
Date of influenza vaccination (if applicable)
DD
/
MM
/
YYYY
8. Does the applicant take any Cytotoxic medication? This is mainly medication used to treat cancer, where gloves would need to be worn for administration.
*
Please select
Yes
No
9. Does the applicant have a diagnosis of any mental health illnesses? If yes, please give details if possible.
*
Please select
Yes
No
10. Has the applicant ever displayed any physical/verbal behavioural problems?
*
Please select
Yes
No
11. Does the applicant ever appear unsettled, exploring, wanting to get out of the house/building?
*
Please select
Yes
No
12. Does the applicant give consent to placement at Derbyshire House, and how do they feel about it?
*
Please select
Yes
No
13. Does the applicant have any MCA/DoLS referrals?
(Mental capacity or deprivation of liberty)
*
Please select
Yes
No
14. Does the applicant have a current DNAR in place?
*
Please select
Yes
No
15. Does the applicant have or has ever had a criminal record/offence? If yes, please explain further.
*
Please select
Yes
No
16. Does the applicant manage their own finances? If No, please explain how finances are currently managed.
*
Please select
Yes
No
17. Does the applicant have a financial power of attorney in place?
*
Please select
Yes
No
18. Does the applicant make any financial decisions?
*
Please select
Yes
No
19. Does the applicant consent to pictures of himself/herself being put on our social media sites? (i.e a picture of the applicant joining in an activity.)
*
Please select
Yes
No
20. Does the applicant consent to pictures of himself/herself being included in our residents and family newsletter?
*
Please select
Yes
No
21. Life History
Please give a brief life history (include: work, children, area/place born)
22. Current situation
Please describe briefly the living/caring situation
23. Cultural values, choices, preferences
In order for us to deliver caregiving, to maximise the wellbeing and preferences of the applicant, please describe their values, what is important to them and their character
24. Routine
Is there anything important to the applicant that is part of their routine i.e., fish on a Friday, church on a Sunday, a particular group/game, or something as simple as wine with lunch.
25. Does the applicant use or believe in any alternative therapies?
This can be their own therapies for example – medication or something as simple as eating certain foods to help ailments.
26. Preferences
Please describe the likes, dislikes and personal preferences of the applicant’s diet.
Do you have any pets? If yes please fill in the next section, if not jump to question 28.
27 Pets
Details
What kind of animal(s) is it (are they)?
How old is it (are they)?
Does it (they) have any health concerns?
Does it (they) have any behavioural concerns?
How long have you had it (them)?
Where was it (were they) from? (e.g. rescue or otherwise)
Does it (do they) have a history of aggression?
Does it (do they) get on well with other animals?
What would you like to happen to it (them) if you moved to a care home?
28. Further information
Please give any further information that you feel would help the home provide a holistic, person centred service.
