Health And Care Details
MEDICAL or PROFESSIONAL REFERRALS please give details
Please provide details of any pending or awaited medical referrals that are not covered elsewhere in this form. This should include anything that has been discussed with a GP or Social Worker but further action not yet taken.
Personal Care etc. Please complete all that apply – please give full and detailed information as this enables us to fully consider how we can meet the applicants needs
1. Can the applicant care for his/ her own personal hygiene? Eg washing, dressing, etc.
2. Is the applicant incontinent?.
3. Do they need reminding to use the toilet?
4. Can they use the toilet independently?
5. If applicable – Does the applicant shave?
6. If applicable - does the applicant require help with her period?
7. Can they make the bed and care for their room?
8. Can they choose their own clothes and dress themselves?
10. Can they get ready for bed unaided?
11. Can they get up in a morning without assistance?
12. Is any assistance required during the night?
13. Does the applicant have any problems sleeping?
14. Does the applicant have disturbed nights – eg do they get up and wander around at night?
15. Does the applicant have any allergies?
19. Can the applicant distinguish between reality and fantasy?
20. Is the applicant sexually aware?
21. Are there any inappropriate sexual behaviours of which we should be aware?