Patient Details Home > Patient Details Personal details Personal Details: Type of Stay:Full timeRespiteNo of hours/week/s:DateName *Date of Birth *Religion (Optional)Languages SpokenGender *MFID details *Mobile *Email *Ref By *Ref. Mobile *Ref. Email *Referral reasonAddressLand MarkFamily Member Emergency Details *Relation with Patient *Family Mobile *Family AddressEmailGuardian/NOK details *Relation with Patient *Guardian Mobile *Guardian AddressGuardian EmailMedical History (brief)Doctor’s DetailsName *Mobile *EmailAddressDoctor comments summary / Additional Information : Medical history/diagnosisMedical History/conditionMedication Management (As Applicable).Information to be provided by Patient’s DoctorDate:DatePatient medicines:Drug nameDoseFrequencyDurationLast TakenAdd itemRemove itemDoes Patient have the medication with her/him?YesNoIs the Patient able to administer own medication?YesNoPlease specify any anticipated side effects of medication:Physical Status Please list any pre-existing medical conditions or allergies.Cognitive Status Please list any cognitive issues to which AHC Carer need to be alerted, e.g. orientation to time and place; independence in decision making; memory impairment; other.Les-Ability (disability): If anyPrimary Les-ability:Hospital and Doctor Details (Name, Email, Address):Mental Health Status Please specify any mental health issues to which Carer needs to be alerted.BehaviorList any behaviour Self-harmDepressionSelf-motivationCapacity for cooperationPhysical aggressionWanderingCapacity to shareCapacity to socialiseVerbal aggressionAlcoholImpulse controlOtherBehaviour Details:List any known “Triggers” (anger/aggression, etc) for problem behaviour:S.NOIf you answer "Yes" pl provide further information.YES / NO1)Have you been told by a doctor or other health professional that you have a health condition (eg breathing problems, a cancer, heart problems, chronic kidney disease, diabetes, high blood pressure, arthritis, osteoporosis or other condition)?YESNO2)Have you recently had problems with your teeth, mouth, gums or dentures?YESNO3)Are you concerned about your medications?YESNO4)Are you concerned about your lack of physical activity?YESNO5)Are you concerned about your weight?YESNO6)Have you recently lost weight without trying?YESNO7)Do currently smoke tobacco or take Alcohol?YESNO8)How is your financial situation ?. who pays your bills/chargesYESNO9)Do you often feel sad or depressed?YESNO10)Do you often feel nervous or anxious?YESNOHTML11)Have you felt afraid of someone who controls or hurts you?YESNOHTML12)Are you at risk of neglect or being homelessness?YESNO13)How would you rate your health as poor/medium/Healthy?YESNO14)How would you rate your Life circumstances as poor/medium/Healthy?YESNOPersonal Care No AssistancePrompting/ SupervisionActive AssistanceEating/drinking/dietOption 1Option 2Option 3MobilityOption 1Option 2Option 3Showering/bathing Option 1Option 2Option 3Shaving/grooming Option 1Option 2Option 3DressingOption 1Option 2Option 3Dental hygieneOption 1Option 2Option 3ToiletingOption 1Option 2Option 3Foot care/nail careOption 1Option 2Option 3LaundryOption 1Option 2Option 3HousekeepingOption 1Option 2Option 3Describe other issues and details:Does Patient use any aids or appliances? MobilityStickFrameWheelchairOtherCommunicationGlassesHearing AidInterpreterOtherOtherDenturesContinence aidsCommentsCommunity Living SkillsIs the Patient able to Ride/Drive/walk/access public transport? YesNoIs the Patient able to make and keep appointments?YesNoRecreation/SocializationIf the Patient likes to do and attends any community based social activities, please provide details:If the Patient has interests or hobbies, please provide details:Relevant Health and Community ServicesOther relevant information/additional details: Pl include what Patient expects from AHC and Carer in detailPatient and Carer Expectations/ObligationsPatient Obligations (to check with any standard government guidelines??) (Terminate this contract by phone or email if not happy with our services/carer by giving 20 days notice) Patient shallMake payments in due time at all times Patient abides by obligations as per this contract Will not be asked to do house tasks/work or any other work apart from patient care needs Shall be treated with respect, dignity and respect as any household members and all duties limited to Patient only All complaints to forwarded to the Office either by phone or email For any incidents pl notify to the office and where relevant to lodge complaint to the police To give all contacts to Carer and office: [next of kin, relatives (if any), doctor, incase of emergency Carer Obligation: - Carer shall: Will not be asked to do house tasks/work or any other work apart from patient care needs Will undertake care and assistance of the Patients as per care plan/list Will not be asked to do house tasks/work or any other work Shall be treated with respect, dignity and respect as any household members and all duties limited to Patient only Shall be entitled to 2 days per month eave A replacement Carer will be provided while on regular Carer on leave All complaints to forwarded to the Office either by phone or email For any incidents pl notify to the office and where relevant to lodge complaint to the police In case of emergency our Carer will follow protocols as dictated by doctors, family members if advised in writing, if not patient will be transported to nearby hospital (all costs to be borne by patient and family Basic Care and support will as per care plan (if available) stipulated by doctor and other health professionals Carer will be on site as per agreement Carer will be responsible to do any task outside the agreement Payment detailsAmount chargedDate receivedAmount receivedBalance paymentBalance due dateCarer nameCarer signDateMode of paymentsPatient name/Next of KinAHC Staff name;Signature:SignatureDateDateFor office Use onlyHTML Issue a signed copy to patient and upload copy on the computer Organise Carer for induction/initial training AHC: Frequency of followup with Patient and carer performance constraints : after 24 hours, second followup after 10 days and then repeat every month Submit