HOME ENVIROMENT Accommodation □ □ □ □ □ House Bungalow Flat Warden Controlled Other Detail any e.g. parking, key safe details Problems with access Safety Factors Are there 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: Prognosis: (No. of days/weeks) 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 drugs 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 needs and continence: Please indicate if the patient has a catheter, or wears incontinent pads
HOME ENVIROMENT Accommodation House □ Bungalow □ Flat □ Warden Controlled □ Other □ Detail any Problems with access e.g. parking, key safe details Safety Factors Are there 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: Prognosis: (No. of days/weeks) 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 drugs 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 needs and continence: Please indicate if the patient has a catheter, or wears incontinent pads
Hospice%20at%20Home%20Referral%20Form%20April%202018.docx