Please answer the following questions: Do you have Social Worker? Yes No If yes please give name and contact details if known: Do you receive any of these Home Care Private Care Day Care services? Do you have any mobility Yes No problems? If yes please tell us what help /aids / assistance you require: Which type of transport will Ring and Ride Public Transport Relative Other you be using? Do you have any problems Yes No with your memory? If yes please explain what support you would need to access this service and assistance required whilst at the Lunch Club: Are you registered blind or Yes No partially sighted? If yes will you require assistance to move around the building / access toilet area: Do you have a hearing Yes No impairment? Are you diabetic? Yes No If yes, are you controlled by: Diet Medication Insulin Please list medication taken: Special dietary requirements: i.e. low fat etc Please describe any further information with regards to your health and details of any support you may require to access this service: Please return this form to: Age UK Oldham, 10 Church Lane, Oldham OL1 3AN - 0161 633 0213 Or email to: or
Please answer the following questions: Do you have Social Worker? If yes please give name and contact details if known: Yes No Do you receive any of these services? Home Care Private Care Day Care Do you have any mobility problems? If yes please tell us what help /aids / assistance you require: Yes No Which type of transport will you be using? Ring and Ride Public Transport Relative Other Do you have any problems with your memory? If yes please explain what support you would need to access this service and assistance required whilst at the Lunch Club: Yes No Are you registered blind or partially sighted? If yes will you require assistance to move around the building / access toilet area: Yes No Do you have a hearing impairment? Yes No Are you diabetic? If yes, are you controlled by: Please list medication taken: Yes No Diet Medication Insulin Special dietary requirements: i.e. low fat etc Please describe any further information with regards to your health and details of any support you may require to access this service: Please return this form to: Age UK Oldham, 10 Church Lane, Oldham OL1 3AN - 0161 633 0213 Or email to: or