Patient Details - Acharya Health Services

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About
Blogs
Gallery
Services
- Senior citizens Living Facilities
- Home Care Services
Volunteers
Contact

Patient Details

Home
About
Blogs
Gallery
Services
- Senior citizens Living Facilities
- Home Care Services
Volunteers
Contact

Home
About
Blogs
Gallery
Services
- Senior citizens Living Facilities
- Home Care Services
Volunteers
Contact

Patient Details

Home

Patient Details

Personal details

Personal Details:

Type of Stay:

Full timeRespite

No of hours/week/s:

Date

Name *

Date of Birth *

Religion (Optional)

Languages Spoken

Gender *MF

ID details *

Mobile *

Email *

Ref By *

Ref. Mobile *

Ref. Email *

Referral reason

Address

Land Mark

Family Member Emergency Details *

Relation with Patient *

Family Mobile *

Family Address

Guardian/NOK details *

Relation with Patient *

Guardian Mobile *

Guardian Address

Guardian Email

Medical History (brief)

Doctor’s Details

Name *

Mobile *

Address

Doctor comments summary / Additional Information : Medical history/diagnosis

Medical History/condition

Medication Management (As Applicable).Information to be provided by Patient’s Doctor

Date:

Date

Patient medicines:

Drug name

Dose

Frequency

Duration

Last Taken

Does Patient have the medication with her/him?YesNo

Is the Patient able to administer own medication?YesNo

Please 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 any

Primary 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.

Behavior

List any behaviour

Self-harmDepressionSelf-motivationCapacity for cooperationPhysical aggressionWanderingCapacity to shareCapacity to socialiseVerbal aggressionAlcoholImpulse controlOther

Behaviour Details:

List any known “Triggers” (anger/aggression, etc) for problem behaviour:

S.NO

If you answer "Yes" pl provide further information.

YES / NO

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)?

YESNO

Have you recently had problems with your teeth, mouth, gums or dentures?

YESNO

Are you concerned about your medications?

YESNO

Are you concerned about your lack of physical activity?

YESNO

Are you concerned about your weight?

YESNO

Have you recently lost weight without trying?

YESNO

Do currently smoke tobacco or take Alcohol?

YESNO

How is your financial situation ?. who pays your bills/charges

YESNO

Do you often feel sad or depressed?

YESNO

10)

Do you often feel nervous or anxious?

YESNO

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11)

Have you felt afraid of someone who controls or hurts you?

YESNO

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12)

Are you at risk of neglect or being homelessness?

YESNO

13)

How would you rate your health as poor/medium/Healthy?

YESNO

14)

How would you rate your Life circumstances as poor/medium/Healthy?

YESNO

Personal Care

No Assistance

Prompting/ Supervision

Active Assistance

Eating/drinking/diet

Option 1Option 2Option 3

Mobility

Option 1Option 2Option 3

Showering/bathing

Option 1Option 2Option 3

Shaving/grooming

Option 1Option 2Option 3

Dressing

Option 1Option 2Option 3

Dental hygiene

Option 1Option 2Option 3

Toileting

Option 1Option 2Option 3

Foot care/nail care

Option 1Option 2Option 3

Laundry

Option 1Option 2Option 3

Housekeeping

Option 1Option 2Option 3

Describe other issues and details:

Does Patient use any aids or appliances? Mobility

StickFrameWheelchairOther

Communication

GlassesHearing AidInterpreterOther

Other

DenturesContinence aids

Comments

Community Living Skills

Is the Patient able to Ride/Drive/walk/access public transport?

YesNo

Is the Patient able to make and keep appointments?

YesNo

Recreation/Socialization

If 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 Services

Other relevant information/additional details: Pl include what Patient expects from AHC and Carer in detail

Patient and Carer Expectations/Obligations

Patient 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 shall

Make 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 details

Amount charged

Date received

Amount received

Balance payment

Balance due date

Carer name

Carer sign

Date

Mode of payments

Patient name/Next of Kin

AHC Staff name;

Signature:

Signature

Date

For office Use only

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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

Acharya Health Care is dedicated to providing exceptional home healthcare services, ensuring that patients receive personalized medical attention.

Our Services

NRI Patient Care Taker Services
Home Nursing Services For Wound
Home Nursing Services For Cororstomy irrigation
Home Nursing Services For Urostomy Patient
Home Nursing Services For Colortormy Patient
Home Nursing Services For Fistula Patient
Nursing Services For Mentally Challenged
Home Nursing Services For Enterostomal Therapy
Home Nursing Services For Breast Cancer Patient

Patient Care Taker Services
Perinatal Care Services
Wet Nurses
Home Nursing Services For Cancer Patient
Home Nursing Services For Senior Citizen
Home Nursing Services For Brain Stroke Patient
Home Nursing Services For TracheoStomy
Senior Citizen Care Taker Services
Home Nursing Services For Bedridden

Contact Details

Address: 46/2, 13th A Main Rd, Jnananjyothinagar, N G E F Empyloyees Layout 2nd Stage, Annapurneshwari Nagar, Bengaluru, Karnataka 560056
Phone: +91 90352 29570
Phone: +91 93804 78200
info@acharyahealth.com
support@acharyahealth.com
accounts@@acharyahealth.com

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