Camberley

Please enable JavaScript in your browser to complete this form.

Service User Full Name

Address

Access Info (Keysafe no. etc)

Date of Birth

Important Contacts

NHS Hospital Number

GP Details

Medical History

Do you give your permission for us to request your medical history from your GP?

List of current Medication and support required – Prompting? Administer?

Allergies – Food, Medication

Pharmacy details (address) – Is medication delivered or collected? How often? Is medication in pharmacy boxes or blister packs?

Registered with a Dentist ?

Power of Attorney in place ? (Obtain Copy)

Do Not Resuscitate order in place? (Obtain Copy)

Hobbies, interests – likes and dislikes

Food and Fluid – meals preferences – main meal lunchtime or evening? Snacks? Drink preference?

Hearing aids ?

Glasses ?

Any walking aids in place? (Frame, Walking Stick) Anything in the Bathroom? Any grab rails around the property?

Additional Moving & Handling Equipment – Hoist? Profile Bed? Commode?

Personal Care requirements?

Continence care requirements? – Incontinence Pads? Catheter? Stoma?

Daily routine – Any additional information:

Social Support – Day Centres? Visitors? Outings?

Financial support / Shopping

Housekeeping – (Cleaner/Gardner)

Internal Assessment:

Fuse Box, Gas & Electric box Location?

How is the home heated – Central Heating?

Location of Water stopcock?

Indoor restrictions – Emergency exits?

Locations of smoke alarms / Carbon Monoxide Alarm / Fire Kit (blanket etc) ?

External Assessment

Steps/stairs, Driveway/Ramp?

Emergency Exits?

Outdoor restrictions – Uneven pathways/Gravel?

Other Notes

Save and Resume Later

Sales: 01252 265265

Internal Assessment:

External Assessment

Please contact your local branch to see how Melody Care can help your loved ones remain independent at home

Aldershot
& Farnham

Alton &
Bordon

Camberley
& Frimley

Farnborough
& Fleet

Winchester
& Eastleigh

Live In Care

Aldershot
& Farnham

Alton &
Bordon

Camberley
& Frimley

Farnborough
& Fleet

Live In Care

Aldershot & Farnham

Alton & Bordon

Farnborough & Fleet

Camberley & Frimley

Aldershot & Farnham

Alton & Bordon

Camberley & Frimley

Farnborough & Fleet