Spinal Home Care

Clients Registration Form

Please take a couple of minutes to complete this short form. It will help us find the right assistance for you. Your details

Title (Mr, Mrs, Miss, Ms):
Surname:	Forename:

Address:
Postcode:


Tel No:
Mobile:
E-Mail:


Gender:	Male Female

Date of birth:
Nationality:


Level of Spinal Injury:
Date of Injury:

Height:
Weight:


Do you work?
Occupation:
Do you live alone?
If NO, who lives with you?

Funding:
Is your funding from/by:

Personal Care Assistance Requirements:
Which sort of live-in option do you require?	Respite Carer(s) (normally for short-term and holiday but can be ongoing series) Permanent Care Package (long-term cover involving carers, permanent & employed by us to work on your behalf)

For what dates do you need a carer?
Start Date:
End Date:


Do you want your carer to be:	Male Essential Male Preferred Don't Mind Female Preferred Female Essential

Do you need your assistant to drive?

For which of the following do you need assistance?	Getting up Going to bed Washing Dressing Feeding Shaving Cooking Cleaning Shopping

Bladder Management :	Condom with leg bag In-dwelling Catheter Supra-public Catheter Need for expression Other
	If other please specify:

Is bladder/bowel management carried out by:	Your carer A district nurse Other

Bowel Management :	Suppositories Digital stimulation Enema Manual Evacuation Other
	If other please specify:
Routine of Bowel Evacuation:
eg. daily / two daily

Carried out by :	Carer A district nurse Other

Do you use :	Bed Shower chair

Personal Hygene:
Which method of washing do you use ?	Showering Bedbath Bathing
How often?:
Do you require turning at night?:
If YES how often?:

Moving / Handling:
Do you use:	Hoist Standing transfer Sliding board Other (please specify)


Do you suffer from / are you prone to: :	Pain Autonomic Dysreflex Spasm Severe Cold Low Blood Pressure Skin problems

Do you use a ventilator?
Medical Conditions:
Other than the spinal injury itself, do you have / have you ever had any other illnesses or medical conditions

If YES, please describe

Additional Information:

Is there anything which may affect your choice of carer (eg if you have pets), or forthcoming holidays?

Today's date?