Enter the name you like to be called inside.
The area (not the address) where you live and how long you have lived there.
This may be a spouse, relative, friend or carer.
Include anything you feel is important and will help staff to get to know and care for you, eg I have dementia, I have never been in hospital before, I prefer female carers, I am left-handed, I am allergic to ... , other languages I can speak.
Include place of birth, education, marital status, children, grandchildren, friends and pets. Any religious or cultural considerations.
Include career history, voluntary experience, clubs and memberships, sports or cultural interests.
What time do you usually get up/go to bed? Do you have a regular nap or enjoy a snack or walk at a particular time of the day? Do you have a hot drink before bed, carry out personal care activities in a particular order, or like to watch the news at 6pm? What time do you prefer to have breakfast, lunch, and evening meal?
Include anything you may find troubling, eg family concerns, being apart from a loved one, or physical needs such as being in pain, constipated, thirsty or hungry. List environmental factors that may also make you feel anxious, e.g. open doors, loud voices or the dark.
Include things that may help if you become unhappy or distressed, eg comforting words, music or TV. Do you like company and someone sitting and talking with you or do you prefer quiet time alone?
Can you hear well or do you need a hearing aid? How is it best to approach you? Is the use of touch appropriate?
Do you wear glasses or need any other vision aids?
How do you usually communicate, eg verbally, using gestures, pointing or a mixture of both? Can you read and write and does writing things down help? How do you indicate pain, discomfort, thirst or hunger? Include anything that may help staff identify your needs.
Have I you had any falls, had a C.V.A(Stroke), and if so what if any disabilities because of it. Are you a diabetic and if so are you Type 1 or 2
How are you on a normal day, are you happy, moody, do you like to chat a lot. Can you be aggressive/agitated etc
List your usual practices, preferences and level of assistance required in the bath, shower or other. Do you prefer a male or female carer? Do you have preferences for brands of continence aids, soaps, cosmetics, toiletries, shaving, teeth cleaning or dentures? Do you have particular care or styling requirements for your hair? Do you need help to take medication? Do you prefer liquid medication?
Have I you had any falls, had a C.V.A(Stroke), and if so what if any disabilities because of it. Are you a diabetic and if so are you Type 1 or 2
Do you have any allergies we should know about, as in Food, Medication, Bee/Wasp stings, washing powder etc and if so how do you react? Do you need an Epee Pen?
Do you need assistance to eat or drink? Can you use cutlery or do you prefer finger foods? Do you need adapted aids such as cutlery or crockery to eat and drink? Does food need to be cut into pieces? Do you wear dentures to eat or do you have swallowing difficulties? What texture food is required to help - soft or liquidised? Do you require thickened fluids? List any special dietary requirements or preferences including being vegetarian, and religious or cultural needs. Include information about your appetite and whether you need help to choose food from a menu.
Include additional details about you that are not listed above and help to show who you are, eg favourite TV programme or places, favourite meals or food you dislike, significant events in your past, expectations and aspirations you have.
Do you like to go out on trips etc, and if so do you get car sickness. Do you like to rest after lunch? Do you like to listen to music?
Indicate any advance plans that you have made, including the person you have appointed as your attorney, and where health and social care professionals can find this information.
