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CARE ASSESSMENT

LOCATION OF CARE SERVICE
House Number/Name, Street Address Line 2 Town / City County Postcode
Your carer
Service Commencement:
- As soon as possible (7 working days)
Gender of Carer:
- Female
- Male
- Not important
Level of English:
- Communicative
- Intermediate
- Fluent
Age of Carer:
- 20-30
- 31-40
- 41-50
- 50+
- Not Important
Care experience:
- Required
- Desirable
- Not important
Driving licence required:
- Yes
- No
Is smoking permitted?
- Yes
- No
- Not important
- Only outdoors
Carer’s accommodation:
- Own bedroom
- Own bedroom with ensuite
- TV
- Other
Other accommodation conditions for carer:
Internet - WiFi:
- Yes
- No
Other requirements for the carer:

PATIENT DETAILS
Number of patients:
- Single patient
- Couple

FIRST PATIENT’S INFORMATION
Patient’s First Name:
Patient’s Surname:
Gender:
- Female
- Male
Weight in stones/pounds (st/lb):
Age:
Type of care:
- Low dependency
- Mid dependency
- High dependency
- Couple care
Community nursing service provided:
- Yes
- No
Mobility Level:
- Fully mobile
- Minor walking disability
- Wheelchair
- Bedridden
Patient’s health (e.g. cancer stage, dementia stage):
Patient’s medication – please specify (e.g. insulin, sedatives):
Patient’s medical condition(s):
- Alzheimer’s
- Arthrosis
- Dementia
- Dialysis patient
- Intellectual disability
- Cardiovascular
- Incontinence
- Double Incontinence
- Cancer
- Stroke
- Multiple sclerosis
- Osteoporosis
- Parkinson’s
- Rheumatism
Other conditions:
Personal Care requirements:
- Dressing, undressing, washing and bathing
- Assistance with toileting
- Personal grooming - teeth and hair care
- Assistance with mobility
- Assistance with feeding
- Skin and pressure area care
- Administering medicines
- Housekeeping and social duties, companionship
- Shopping
- Preparing food and cooking meals
- Pet care
- Housework
- Driving
Other care requirements:
Moving and handling required?
- Yes
- No
Diet:
- Traditional English
- Vegetarian
- Other
Other diet:
Patient’s daily routine:
Special equipment:
- Hoist
- Stair lift
- Bath lift
Other special equipment (please give details):

SECOND PATIENT’S INFORMATION
Patient’s First Name:
Patient’s Surname:
Gender:
- Female
- Male
Weight in stones/pounds (st/lb):
Age:
Type of care:
- Low dependency
- Mid dependency
- High dependency
- Couple care
Community nursing service provided:
- Yes
- No
Mobility Level:
- Fully mobile
- Minor walking disability
- Wheelchair
- Bedridden
Patient’s health (e.g. cancer stage, dementia stage):
Patient’s medication – please specify (e.g. insulin, sedatives):
Patient’s medical condition(s):
- Alzheimer’s
- Arthrosis
- Dementia
- Dialysis patient
- Intellectual disability
- Cardiovascular
- Incontinence
- Double Incontinence
- Cancer
- Stroke
- Multiple sclerosis
- Osteoporosis
- Parkinson’s
- Rheumatism
Other conditions:
Personal Care requirements:
- Dressing, undressing, washing and bathing
- Assistance with toileting
- Personal grooming - teeth and hair care
- Assistance with mobility
- Assistance with feeding
- Skin and pressure area care
- Administering medicines
- Housekeeping and social duties, companionship
- Shopping
- Preparing food and cooking meals
- Pet care
- Housework
- Driving
Other Care requirements:
Moving and handling required?
- Yes
- No
Diet:
- Traditional English
- Vegetarian
- Other
Other diet:
Patient’s daily routine:
Special equipment:
- Hoist
- Stair lift
- Bath lift
Other special equipment (please give details):

ACCOMMODATION CONDITIONS
Are night duties required (waking up to provide assistance)?
- No, no more than once per week
- Yes, maximum once per night
- Yes, several times per night
Pets:
- Cat
- Dog
Other pets:
Accommodation details:
- House
- Apartment
- Urban
- Countryside
- All shopping located within walking distance
Additional activities in the household:
- Taking care of pets
- Ironing
- Watering flowers
- Cleaning windows
- Light garden duties
- Meal planning
- Laundry
Other additional activities in the household:

Your details
Title
First name:*
Surname:
ADDRESS
House Number/Name, Street Address Line 2 Town / City County Postcode
Email:*
Phone Number*
How did you hear about Veritas Care?
Write How you did hear about us:*
*
- I hereby agree to the processing of my personal data, including health data, by the Veritas Care LTD for the purpose of contacting me and providing details of the care services offered. I hereby acknowledge that I have the right to withdraw my consent at any time
- I hereby agree to receive from Veritas Care Ltd in Basingstoke, via email, SMS/MMS and by phone the marketing content containing information about the Veritas Group services, consumer research, contests, promotions and events organized by the entities belonging to the Veritas Group.

LOOKING FOR CARE?
CALL 0800 731 8671

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VERITAS CARE LTD Basepoint Enterprise Centre, Stroudley Road, Basingstoke, Hampshire, RG24 8UP tel: 0208 133 4580

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LOOKING FOR CARE? CALL 0208 133 4580