Care Plan
Date of Assessment
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Status
*
Please Select
Active
Inactive
Cared For Name
*
First Name
Last Name
Date Of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Carers Name
*
First Name
Last Name
Telephone contact information
*
Detail whom to call, including their relationships and phone numbers
0/255
Carer To Let In
Yes
No
Key Safe Number
Housing information
*
Detail specific home arrangements e.g assisted living
0/255
Disabilities
*
None
ADHD
Alzheimer's
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Autism
Bad back
Bedridden
Bi-lateral hearing loss
Bi Polar
Brain Bleed
Breast Cancer
Calcification of the eyes
Calcification of the hips
Cancer
Cardiomyopathy
Cataract
Cerebral Palsy
Challenging Behaviour
Chronic Kidney Disease
Compulsive disorders
Constipation
COPD
Creutzfeldt-Jakob disease
Cystic Fibrosis
Dementia
Dementia with Lewy bodies
Depression
Diabetes
Downs Syndrome
DVT
Dyspraxia
Elderly/Frail
Epilepsy
Fibromyalgia
Fragile X Syndrome
Frontotemporal Dementia
Galactoservia (severe brain damage)
Global Developmental Delay
Hard of hearing
Hayfever
Heart Condition
Hemiplegia
High Blood Pressure
Huntington's Disease
Hydrocephalus
Hypermobility
Hypoxic brain injury
Incarcerated Hiatus Hernia
Korsakoff's syndrome
Learning Difficulty
Leukaemia
ME
Microcephaly
Mixed Dementia
Motor Neurone
Multiple Sclerosis
Obessions
OCD
One Kidney
Osteoporosis
Other (please specify)
Parkinson's disease
Partially sighted
Pleurisy
Poor Mobility
Prostate
Pulmonary fibrosis
Quadrepligic
Reflux
Registered blind
Rheumatism
Schizophenia
Scohosis
Scoliosis
Spina Bifida
Stroke
Tendency to choke
Thyroid
TIA
Tourettes
Triple Heart Bypass
Tube fed
Tuberous Sclerous
Underactive Thyroid
Varicose Vain - Swelling leg
Vascular Dementia
Wernicke-Korsakoff Syndrome
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DNR Location
*
Add n/a if Client does not have a DNR
Other Disabilities
Recovery Medication
*
Please Select
Yes
No
Allergies
*
None
Animal Fur
Asprin
Caffeine
Cats
Celery
Citalopram
Codeine
Crustaceans
Dairy
Dust
Eggs
Fish
Gluten
Hayfever
Kiwi Fruit
Lactose
Latex
Lupin
Molluscs
Mustard
Nuts
Peanuts
Penicillin
Plasters
Sesame
Smoked Salmon
Soya
Tramadol
Voltarol
Wheat
Whitebait
Dogs
Insect Bites
Popcorn
Tree Pollen
Grass Pollen
Raw fruit & veg
Cashew
Hazelnut
Pistachio
Lilies
Omeprazole
Bee/wasp stings
Guinea pig fur
Stemetil
Other
Use Ctrl or Command to select multiple entries
If Other Please Specify:
GP Details (If applicable)
CLIENT SPECIFIC INFORMATION
About the Client
*
Detail family, previous occupation, where grew up etc
0/500
A typical day
*
Detail daily routine
0/500
Specific Client Behaviours
*
Detail challenging behaviours, possible triggers, dangers etc
0/500
Likes & Dislikes
*
0/255
Team Leader recommendations
*
Suggested distractions
*
EATING
Eating & Drinking Specific Information
*
0/500
Do they have difficulty swallowing?
*
Yes
No
PERSONAL CARE
Personal care requirements
*
0/500
MOBILITY
Mobility Information
*
0/500
CONSENT FORMS
Consent for days out/trips:
*
Please Select
Yes
No
N/A
Consent for photos on social media:
*
Please Select
Yes
No
N/A
Consent for photos on website and other marketing materials:
*
Please Select
Yes
No
N/A
SIGNATURES
By signing this Care Plan, you are agreeing the information given is an accurate reflection of the client you are enrolling.
Client or Carer Name
First Name
Last Name
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Client or Carers signature
Assessor Name
*
First Name
Last Name
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Assessor signature
*
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