CARERS QUESTIONNAIRE

Who is a carer?A carer is someone, who, without payment, provides help andsupport to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to being elderly, physical or mental illness, addiction or disability.

We would be grateful if you could complete the following questions. We will then record this information on the practices Carer’s Register. A carer’s register enables the practice to proactively manage carer’s needs within the practice and to consider the provision of services to carers. The practice will also ensure that all patients who are carers are informed of and supported in joining the local carer’s link.

1. Please complete this section if you are a carer

Are you a carer? / Yes / No
If yes, what is your relationship with the person you care for?
Are you registered at this practice? / Ye s / No
Details of Carer / Details of the person being cared for
Title / Title
Surname / Surname
Forename / Forename
DOB / DOB
House name/Flat / House name/Flat
No. and street / No. and street
Village / Village
Town / Town
Postcode / Postcode
Telephone / Telephone

2.Please complete this section if you are being cared for

Are you being cared for by someone? / Yes / No
What is your relationship with the person who cares for you?
Are they registered with this practice? / Yes / No
NHS Number
Details of the person being cared for / Details of Carer
Title / Title
Surname / Surname
Forename / Forename
DOB / DOB
House name/Flat / House name/Flat
No. and street / No. and street
Village / Village
Town / Town
Postcode / Postcode
Telephone / Telephone

If you consent to your Carer being informed of any medical information about you which is held at Ipplepen and Kingskerswell Health Centre then please sign and date below.

Signed………………………………………………………….Date…………………

{ } Tick here if signed by adult on behalf of child.

Readcode Ub1juYesRelationship Created Yes

© Kingskerswell & Ipplepen Medical Practice