INFORMAL CAREGIVER INFORMATION No Carer Available Carer/Care Representative: By we mean someone you rely on to help with daily life, but is not paid to do so ‘carer’ – meaning a family member, friend or relative. By designating a carer, you authorize this individual to be part of your care team and assist with implementing your care plan upon leaving the hospital, assist organizing follow up services as needed, and support ongoing communication of needs and concerns to your care team. Carer understands role on care team and accepts designation. YES NO *Add carer contact information if not already entered under alternative contact information. DEMOGRAPHIC INFORMATION Gender: Male □ Female □ Unknown □ Height: Weight: ________________ Race: American Indian/Alaskan Native White/Caucasian □ □ Asian Multi-Racial □ □ Black/African American Unknown □ □ Native Hawaiian/Pacific Islander □ Ethnicity: Hispanic/Latino □ Not Hispanic/Latino □ Marital Status: Single/Never Married Civil Union/Domestic Partnership □ □ Married Cohabitating with Partner □ □ Separated Other: ________________________ □ □ Divorced Prefer Not to Say □ □ Widowed □ Where are you living right now? Own house/Apartment Institutional setting, specify____________ □ □ With friend/relative Other: ________________ □ □ SRO/boarding home □ Does the patient have lack of social support at home Yes No
INFORMAL CAREGIVER INFORMATION Carer/Care Representative: No Carer Available By ‘carer’ we mean someone you rely on to help with daily life, but is not paid to do so – meaning a family member, friend or relative. By designating a carer, you authorize this individual to be part of your care team and assist with implementing your care plan upon leaving the hospital, assist organizing follow up services as needed, and support ongoing communication of needs and concerns to your care team. Carer understands role on care team and accepts designation. YES NO *Add carer contact information if not already entered under alternative contact information. DEMOGRAPHIC INFORMATION Gender: □ Male □ Female □ Unknown Height: Weight: ________________ Race: □ American Indian/Alaskan Native □ White/Caucasian □ Asian □ Multi-Racial □ Black/African American □ Unknown □ Native Hawaiian/Pacific Islander Ethnicity: □ Hispanic/Latino □ Not Hispanic/Latino Marital Status: □ Single/Never Married □ Civil Union/Domestic Partnership □ Married □ Cohabitating with Partner □ Separated □ Other: ________________________ □ Divorced □ Prefer Not to Say □ Widowed Where are you living right now? □ Own house/Apartment □ Institutional setting, specify____________ □ With friend/relative □ Other: ________________ □ SRO/boarding home Does the patient have lack of social support at home Yes No
10.1001stepsforward.2017.0109supp7.docx