If YES, please give reasons why: Yes No Does the person have a working smoke detector? Yes No Is the person using medical oxygen in their property? Yes No Does the person/anyone in the household smoke Yes No If yes, does the person smoke in bed? Yes No Does the person have difficulties with their hearing? Yes No Does the person rely on others or equipment to move around their home freely? If YES, please provide further details Yes No Do you have any other concerns relating to the person’s safety and maintaining their independence If YES, please provide further details below: Yes No 1 Please provide details on Main Living Room Hallway Bedroom location for the main telephone point within Kitchen Other the home: Is there a power socket within two metres of the Yes No phone socket located on the same wall?
Yes No If YES, please give reasons why: Does the person have a working smoke detector? Yes No Is the person using medical oxygen in their property? Yes No Does the person/anyone in the household smoke Yes No If yes, does the person smoke in bed? Yes No Does the person have difficulties with their hearing? Yes No Does the person rely on others or equipment to move around their home freely? Yes No If YES, please provide further details Do you have any other concerns relating to the person’s safety and maintaining their independence Yes No If YES, please provide further details below: 1 Please provide details on location for the main telephone point within the home: Main Living Room Hallway Bedroom Kitchen Other Is there a power socket within two metres of the phone socket located on the same wall? Yes No
telecare_application_form_v1_3_5.docx