Initial Assessment APPOINTMENT DETAILS Assessment Date Assessors 1 Assessors 1Betsy BarlowJess AmesKaty MarcusLagin RieckerMarlene RieckerMaria StackDavid Platts Assessors 2 Assessors 2Betsy BarlowJess AmesKaty MarcusLagin RieckerMarlene RieckerMaria StackDavid Platts Start Date Type of care: Type of care: Live-in Care Night Care Domiciliary Care Day Club CLIENT'S PERSONAL DETAILS Title TitleMrMrsMissMs First Name I like to be called Last Name Date of Birth Ethnicity EthnicityAsian or Asian BritishBlack, Black British, Caribbean or AfricanMixed or multiple ethnic groupsWhiteOther ethnic group Address Post Code Marital Status Marital StatusSingleMarriedDivorcedWidowedSeperated Landline Number Mobile Number Email EMERGENCY CONTACT DETAILS Name of 1st contact Relationship RelationshipSonDaughterParentFriendSolicitorSocial WorkerOther Mobile Number Landline Number Address Post Code Email Name of 2nd contact Relationship RelationshipSonDaughterParentFriendSolicitorSocial WorkerOther Mobile Number Landline Number: Address Post Code Email: GP DETAILS Name of GP Address Post Code Telephone Number OTHER PROFESSIONALS Professionals Involved: Professionals Involved: Chiropodist Social Worker Community Nurse (CN) Occupational Therapist (OT) Speech & Language Therapist (SALT) Hospice (EOL) CARE PLAN DETAILS Medical Conditions/Disabilities/Medical History Do you drink alcohol? Do you drink alcohol?YesNoSometimesSociallyVery little Do you smoke? Do you smoke?YesNoSometimesSocially Do you have a Power Of Attorney (POA)? Do you have a Power Of Attorney (POA)?YesNo Do you have a DNAR? Do you have a DNAR?YesNo Additional Comments If yes, in which type? If yes, in which type? Health & Welfare Property Finance Who holds this? Who holds this?SonDaughterParentFriendSolicitorSocial WorkerOtherMultiple Additional Comments Any problems swallowing tablets? Any problems swallowing tablets?YesNoSometimes Do you have any allergies? MEDICATION Support/Administering (Level): Support/Administering (Level): Level 1 - Self Administration (prompt) Level 2 - Care Worker Administration Level 3 - Specialist Techniques Blister packs or Original Boxes? Blister packs or Original Boxes?Blister PacksOriginal Boxes Where do you keep your medication? List of medications Do you take an bloodthinners (anticoagulants)? Do you take an bloodthinners (anticoagulants)?YesNoOther Bloodthinners (Anticoagulants) Controlled Medication? Who is responsible for reordering? Who is responsible for reordering?ClientCare workerSonDaughterParentFriendSolicitorSocial WorkerOther How is your medication received? PHARMACY Name of Pharmacy Address Telephone Number CONTINENCE How continent are you? How continent are you? Continent Urinary incontinence Faecal incontinence Doubly incontinent Some accidents Do you use pads? Do you use pads? Yes No Sometimes Additional Comments Do you have yellow bags in place? Do you have yellow bags in place? Yes No To be organised Do you have stoma care? Do you have stoma care?YesNo Do you have a catheter? Do you have a catheter?YesNo MOBILITY Mobility Level: Mobility Level: Very Mobile & Active Weak but can walk short distances Unable to stand unassisted Unable to hold body weight Fully Hoisted Equipment being used: Equipment being used: No equipment Walking stick Zimmer Frame Wheelchair Bath Chair Profile Bed Wendyletts/ETAC Satin Sheets Sara Stedy Ambiturn/Rota Stand Minilift/Standing Hoist Mobile Hoist Gantry Hoist Ceiling-Track Hoist Other Additional Comments Mobility Assistance: Mobility Assistance: Single-Handed Transfers Double-Handed Transfers Single-Handed Hoisting Double-Handed Hoisting Additional Domiciliary Assistance Other PERSONAL CARE Type of wash: Type of wash: Basin wash Bed wash Shower Bath Full Assistance No Assistance needed Additional Comments PREFFERED ROUTINES Likes/Dislikes/timings of calls/ regular appointments FLUIDS & NUTRITION Fluids Level: Fluids Level: Too little Good Medium Poor Too much Nutrition Level: Nutrition Level: Too little Good Medium Poor Too much Additional Comments COMMUNICATION & MEMORY Hearing level: Hearing level: Good Medium Poor Hearing Aid left ear Hearing Aid right ear Hearing Aids both Additional Comments Sight level: Sight level: Good Medium Poor Glasses short sighted Glasses long sighted Registered Blind Additional Comments Short-Term Memory Level: Short-Term Memory Level: Good Medium Poor Long-Term Memory Level: Long-Term Memory Level: Good Medium Poor Communication Level: Communication Level: Good Medium Poor Non-Verbal KEEPING SAFE Safety Considerations: Safety Considerations: Gas metre Trip switch Key Safe Link alarm Smoke alarm Additional Comments ABOUT YOU Hobbies & Interests? Work History? Do you have any children? Do you have any grandchildren? Do you have any great grandchildren? Have you always lived here? CULTURAL & SPIRITUAL NEEDS Religion: Religion: Atheist Agnostic Bhuddist Christian Muslim Other How can we further support you with your beliefs? RISK FACTORS Risk Factors: Risk Factors: Falls UTI's Bedsores Mobility Equipment Choking Other Additional Comments? FINANCIAL DETAILS Payee Name: Payee Address: Payee Email: Method of invoice: Method of invoice: Post Letter Email PDF Additional Comments? Funding: Funding: Privately funded West Sussex County Council (WSCC) Council Managed Budget (CMB) Continuing Health Care (CHC) Personal Health Budget (PHB) Other END OF ASSESSMENT 15 + 10 = Complete
