Detail any e.g. parking, key safe details Problems with access Safety Factors Are any smokers in the home? Are there pets in the home? □ □ □ □ Yes No Yes No Problems with Is there lack of adequate facilities eg. Heating, cleanliness? comfort MEDICAL DETAILS Primary Diagnosis: Known Metastases: Date of Diagnosis: Other Medical Conditions: Adverse Drug Reactions: □ □ Pacemaker: Yes No Consultant(s): Hospital: Hospital number: Current Medication: Medication sent home with G.P. Authorisation sheet in the patient: home? □ □ Yes No End of Life prescribed? □ □ Yes No Current Health Problem (In addition to above) Current mobility: Can the patient move independently or with assistance? What equipment is in situ or on order ? e.g hospital bed, slides sheets. Hygiene and continence: Please indicate if the patient has a catheter, or wears incontinent pads Eating/drinking: Is the patient eating and drinking? Any special dietary problems? Any problems with swallowing? Routes of medication: Please indicate if help is needed to take medication. Is there a syringe driver box in the home? Communication: Please indicate any difficulties with communication
Detail any Problems with access e.g. parking, key safe details Safety Factors Are any smokers in the home? Yes □ No □ Are there pets in the home? Yes □ No □ Problems with comfort Is there lack of adequate facilities eg. Heating, cleanliness? MEDICAL DETAILS Primary Diagnosis: Date of Diagnosis: Known Metastases: Other Medical Conditions: Adverse Drug Reactions: Pacemaker: Yes □ No □ Consultant(s): Hospital: Hospital number: Current Medication: Medication sent home with patient: G.P. Authorisation sheet in the home? Yes □ No □ End of Life prescribed? Yes □ No □ Current Health Problem (In addition to above) Current mobility: Can the patient move independently or with assistance? What equipment is in situ or on order ? e.g hospital bed, slides sheets. Hygiene and continence: Please indicate if the patient has a catheter, or wears incontinent pads Eating/drinking: Is the patient eating and drinking? Any special dietary problems? Any problems with swallowing? Routes of medication: Please indicate if help is needed to take medication. Is there a syringe driver box in the home? Communication: Please indicate any difficulties with communication