CLIENT PROFILE AND INITIAL NEEDS ASSESSMENT FORMS

Confidentiality Statement:

Information recorded on this form will be treated with the utmost
confidentiality, in accordance with our data protection obligations under
the General Data Protection Regulation (GDPR) and any applicable
local data protection laws.

1. Personal Information

Full Name*

First NameLast Name

Date of birth*

Date

Preferred name*

2. Contact Details

Main Permanent Residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Main Phone Number*

Alternative Phone Number (optional)

Email Address (If Applicable)

Preferred method of Contact*

Key Safe (If Applicable)

3. Important Contacts

GP Information*

Next of Kin*

NOK main Phone Number*

NOK alternative Phone Number (optional)

Next of Kin Email*

example@example.com

Other people who are important to you:

Healthcare Teams involved in managing your chronic conditions (for example District Nurses etc)

Social Worker (Name and Phone If Applicable)

4. About Me / Care-Related Information

History/Background information:?*

The things you like to do:*

What upset, irritates, or makes you anxious:*

What makes you feel better when upset, irritated or anxious*

Your Faith/Religion (optional)

How do you communicate?*

Do you wear hearing aids?*

Do you wear glasses?*

Do you wear dentures?*

Do you use any aids for repositioning, transferring or walking?*

Personal Care

Do you need assistance with washing, bathing, or showering?*

Do you need assistance with brushing your teeth?*

Do you need assistance with combing your hair?*

Do you require help with continence care (e.g., changing pads)?*

Eating and Drinking

Do you need help preparing meals (breakfast, lunch, supper)?*

Do you need assistance with eating or drinking?*

Is there a Do Not Attempt Cardiopulmonary Resuscitation form in place (DNACPR, popularly known as RED FORM)*

5. Medical History / Medication

What is your medical history? (Please list all chronic conditions or attach the most recent hospital discharge letter.)*

File Upload (If possible, please attach a copy of your most recent discharge summary or give a copy to management.)

What medications are you currently taking?*

File Upload (If possible, please attach a copy of your repeat prescription or give a copy to management.)

Do you have any medication and/or food allergies?*

How much assistance do you need with taking medication?*

Where is your medication stored? (e.g., blister pack, dosset box, original pack)*

Who orders your repeat prescriptions?*

6. Required Care Visits

How many care visits do you require per day? Please specify your preferred times.*

What tasks do you require carers to complete during each visit?(Please list key responsibilities.)*

7. Method of Funding

Funding Source: (e.g., Private, Local Authority, CCG) — Please specify who will be responsible for handling invoice payments if it is not you directly.*

8. Any other relevant Information

Please provide any other relevant information, that you think will help the carers quickly build a supportive relationship with you.

Person Completing this form*