Nursing Home Application - Horsfall House

Application Form

Step 1 of 6

16%

Service Interested In(Required)

Title(Required)

First Name(Required)

Surname(Required)

Address(Required)

Street Address Address Line 2 City Post Code

Phone(Required)

NHS Number

National Insurance No(Required)

Marital Status(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Next of Kin First Name(Required)

Next of Kin Surname(Required)

Relationship to Applicant(Required)

Next of Kin Address(Required)

Street Address Address Line 2 City Post Code

Next of Kin Email(Required)

Next of Kin Phone(Required)

Next of Kin Mobile(Required)

GP Name & Surgery(Required)

Surgery Tel No

Is your GP willing to retain you as their patient when you enter residential care?(Required)

Will your care be funded(Required)

Day Centre Applicants Only

Is Day Centre transport required?(Required)

Preferred Day Centre days(Required)

Home Care applicants only

Please tick your current requirements.(Required)

Do you have any professional help with daily living?(Required)

If yes, is this from:(Required)

If applicable, please name the agency that assists you.(Required)

Eating and Drinking

Do you have any dietary requirements?(Required)

Yes

Please provide more details(Required)

Do you need assistance with meals?(Required)

Yes

Please provide more details(Required)

Continence Care

Do you require any help with continence care?(Required)

Yes

Other

Please provide more details(Required)

Continence Care

Do you require help with personal care?(Required)

Yes

Do you require help with washing?(Required)

Yes

Do you require help with dressing?(Required)

Yes

Do you require assistance with mobility?(Required)

Yes

Do you need frequent help from a nurse? E.g. a wound or pressure ulcer, injections, oxygen therapy, nutritional monitoring, catheter, PEG feeding tube, Mental Health input (Funded Nursing Care catgeory)(Required)

Yes

Other

Please provide more details(Required)

Do you require any specialist equipment?(Required)

Yes

Other

Please provide more details(Required)

Sight

Do you wear glasses?(Required)

Yes

Other

Do you have a vision related diagnosis?(Required)

Yes

Other

Hearing

Do you have problems with your hearing?(Required)

Yes

Other

Do you use hearing aids?(Required)

Yes

Yes, but with hearing aids

Other

Communication and Memory

Can you express yourself verbally?(Required)

Yes

Do you have a memory problem?(Required)

Yes

Do you have a problem with confusion?(Required)

Yes

Approximate memory diagnosis date?

MM slash DD slash YYYY

Support service input?(Required)

Yes

Sleep

Please describe your sleep pattern

Do you require any specialist equipment or support?(Required)

Yes

Please provide more details(Required)

General Questions

Do you do any of the following?

Wander

Have panic or frightened attacks

Become agitated with your carers

Strike out at anyone

Have any difficulty maintaining your own safety

Have difficulty choosing appropriate clothing

Have any difficulty with your breathing

Please provide more details(Required)

Do you have any problems with your breathing?(Required)

Yes

Please provide more details(Required)

Do you have any beliefs or practise a religion?

First Choice

Second Choice

Third Choice

Do you have any of the following?(Required)

Living Will

Advance Directive

RESPECT Form

Not Applicable

Please provide more details(Required)

Do you have a nominated Power of Attorney for

Property and Finance

Health and Welfare

Not Applicable

Please provide more details(Required)

Do you have a deputy appointed by the court of protection?

At time of admission, copies of relevant documents will be required

Yes

Please provide more details(Required)

Please list any allergies to medications, substances or food(Required)

At time of admission, copies of relevant documents will be required

Please list any medications currently being taken(Required)

Please state your past medical history and any existing medical conditions, including latest vaccinations(Required)

Any other relevant information including interests and hobbies

If you are currently in hospital, please give details

Do you consent for your photograph being taken for use on our Digital Care Plans inline with our Privacy Policy?(Required)

Yes

Do you consent for your photograph being used for marketing and promotional use inline with our Privacy Policy?(Required)

Yes

I would like to hear more about the work of Horsfall House through your newsletters.(Required)

Yes

How did you hear about Horsfall House?(Required)

Word of mouth

Local advert

Social media

Search engine

Recommended to me

CareHome.co.uk

Local council/professional

Other

If other, please give details(Required)

Signed(Required)

I agree that the above information is correct and to the storage of my personal information inline with our GDPR and Privacy Policy for the purposes of processing my application and delivering care.

Signed

Name(Required)

Date(Required)

MM slash DD slash YYYY

Relationship to applicant if signed on their behalf

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.