Care Assessment Tool Personal Information What is your name? What is your date of birth? What is your current address? Do you have a primary contact person?YesNo If yes, what is their name and relationship to you? Health and Medical Needs Do you have any medical conditions or disabilities?YesNo If yes, please provide details: Are you currently taking any medications?YesNo Do you have any allergies?YesNo Do you require assistance with managing your medications?YesNo Daily Living Activities Do you need help with personal care, such as bathing or dressing?YesNo Do you require assistance with meal preparation or feeding?YesNo Do you need help with mobility, such as walking or transferring from bed to chair?YesNo Do you require support with using the toilet or continence care?YesNo Home Environment and Safety Is your home equipped with any special equipment, such as grab rails or stairlifts?YesNo Do you need help with household tasks, such as cleaning, laundry, or shopping?YesNo Social and Emotional Well-being Do you feel lonely or isolated?YesNo Do you have family or friends who visit regularly?YesNo Are there any hobbies or activities you enjoy that you would like help to continue?YesNo Do you require assistance with attending social or community activities?YesNo Care Preferences Do you have any specific preferences for your carers (e.g., gender, language spoken)?YesNo If yes, please provide details: How many hours of care do you think you need each day? Additional Information Is there anything else you would like us to know about your care needs? Stay updated with trustbridgeA Miracle of Resilience: Hassan’s Journey with Encephalitis SynopsisRead MoreHow to Choose the Right Domiciliary Care ProviderRead MoreUnderstanding Sundowning: A Guide for Caregivers of Those with DementiaRead More
