AVON VALLEY PRACTICE
Additional Information
If possible, please complete the following questionnaire. Providing this information promotes improved care by the doctors but also should you require services from other agencies including local hospitals and district nursing teams.
First Name: ......
Surname: ......
D.O.B: ………………......
What is your living accommodation?
¨House ¨Bungalow
¨Mobile home ¨Upper floor flat
¨Ground floor flat ¨Bedsit
¨ Lodgings ¨Temporary
¨Warden attended ¨Residential home
Accommodation ¨Nursing home
¨Homeless ¨Confidential
Who do you live with?
¨Lives with (please specify)
……………………………………………….
¨Live alone (no help available)
¨Lives alone (help available)
Are you able to walk independently?
Yes / No (if yes, please complete the following)
¨Independent walking with difficulty
¨Walks independently with stick
¨Walks independently with frame
¨Independent walking with aids
¨Able to walk with assistance from 1 person
¨ Able to walk with assistance from 2 or more people
¨Unable to walk
¨Confined to chair
¨ Bed ridden
Do you use a wheelchair? Yes / No
If yes, please what type of wheelchair do you use?
¨Uses self propelled wheelchair
¨Uses attendant propelled wheelchair
¨Uses powered wheelchair
Do you have a carer? Yes / No
If yes, what type of carer helps you?
¨Carers involved
¨has a paid carer
¨has voluntary carer
¨has an informal carer
Is your carer readily available? Yes / No
Do you live with your carer? Yes / No
If no, how close does your carer live?
¨Nearby
¨Carer lives at a distance
What does your carer help you with?
¨to help get up / go to bed
¨to help wash / shower / bath
¨to help dressing / undressing
¨to help with feeding
¨to prompt medication
Are you a carer?
Who do you provide care for?
¨a relative
¨a friend
¨a neighbor
¨Other (please specify)
What conditions do they have? Please specify:………………………………….