1. Please let us know your current level of independence and type of support requirements you might have:
2. Do you currently have any type of care support at home?
If so, please indicate what type of support you are currently receiving:
3. Please let us know in which of the ways below you are hoping we can help improve your life:
4. Please indicate how your medications are managed:
5. Let us know what your hobbies are:
6. Please let us know about things that you used to enjoy and still have an interest in:
7. To help us get a feel of what you like and what you enjoy please can you indicate which of the following describe you best:
8. Could you please give us an idea as to how you like your daily routine to go?
9. Please let us know the key things that make you feel at home:
10. How would you prefer to take your meals?
11. What types of food do you normally prefer?
12. Are there any foods that you dislike or have an intolerance/allergy to?
13. We can assist with an in house hairdresser, chiropodists, eye care, dentists etc. would you like to continue with your own or would you like to transfer to ours?
14. Do you normally practice a religion? If so can we help? If not are there other cultural/ spiritual activities that we would need to accommodate?
15. Do you normally need the assistance of the district nurses team for dressings etc.?
16. Please state how well your memory is working.