Get to Know Me Questions
1. What I liked to be called
*
2. Religious Denomination
*
3. Languages I speak
*
4. Previous employment
*
5. Marital Status
*
Single
Married
Divorced
Widowed
6. Emergency Contact:
Name:
First Name
Last Name
Relationship to service user:
Contact Number:
Name:
First Name
Last Name
Relationship to service user:
Contact Number:
7. Health Conditions:
*
8. Medication List:
*
Take a Picture of Medication
9. Panic Alarm/Pendant Alarm:
*
Yes
No
Where is the Alarm located?
Right Wrist
Left Wrist
Neck
Wall Mounted
10. Access to home:
*
Knock on
Intercom
Family will give access
Keysafe
11. Carer Preference:
*
Male
Female
Don't Mind
12. What do you like to have for Breakfast/Lunch/Tea/Bed?
*
13. What's your favourite hot/cold drink?
*
14. Do you have any activities/hobbies?
*
15. What do you like to wear after waking up and when going to bed?
*
16. Tell me about your likes or dislikes?
*
17. Are there any specific tasks or jobs that are of more importance than others when attending to your care needs?
*
18. Emergency Contact Details:
Submit
Should be Empty: