Care Needs

Assessment Form

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Care Needs Assessment Form

First Name

Last Name

Contact Email Address

Phone

CARE RECIPIENT’S PROFILE

Age*

Gender*

MEDICAL CONDITIONS*

(Please state each condition separately and give a brief summary)

MEDICATION NEEDS*

(please state medications and treatments, and any other medical needs)

CARE EXPERIENCE REQUIREMENTS*

PERSONAL CARE*

Wake up time

Bedtime

Bathing assistance

Grooming assistance

Dressing assistance

Toilet in assistance

CONTINENCE NEEDS*

Yes

FOOD, DIET & NUTRITION

Dietary requirements*

Breakfast Time*

Breakfast Description*

Breakfast Snack Time*

Breakfast Snack Description*

Lunch Time*

Lunch Description*

Lunch Snack Time*

Lunch Snack Description*

Dinner Time*

Dinner Description*

Dinner Snack Time*

Dinner Snack Description*

NIGHT TIME & SLEEPING NEEDS*

(Does the care recipient wake up or need assistance during the night?)

CHALLENGING BEHAVIOUR*

BREAKS: IS THE CARE RECIPIENT SAFE TO BE LEFT UNATTENDED FOR UP TO 2HRS Yes/No*

MOBILITY*

(Does the person receiving care need assistance)

COMMENTS

SOCIAL & LEISURE*

CARE ENVIRONMENT*

Household Description*

Visits From Family*

Visits From Friends*

Nearest Train Station*

Shops*

Driving Requirements*

Wifi*

Pets*

Domestic Support*

Groceries*

Food for Carer*

(Food can be provided as part of household or carer can be given £40p/w)

Carer‘s Break Cover 2- 3hrs*

(Recommended times)

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leslyicdigitalCare Needs Assessment Form06.16.2020