Pre-Assessment Form

Please fill this form in with as much detail as you can, filling in all the fields. Once you have submitted the form we will be in contact.

If you have any questions please contact sheena.parker@southdevoncareservices.com or call 07704 573281.

Assessment information

Other sources of information used to make assessment

About the person being assessed

Address (including Postcode)

Reason for admission to a care home

General practitioner details

Surgery name, address and postcode

Dentist details

Practice name, address and postcode

Medical information

Medical health history including surgery/any infections: MRSA/C-DIFF/Scabies/other

Details of medical/Health/Specialist diagnose that will require health promotion care plan

Allergies

Mental Health

Please give full details e.g. Psychiatric history: Depression, Suicidal. Cognition, Confusion, Orientation. Physical/Verbal aggression. Motivation. Sundowning. Memory/ Confusion. Behaviour. Delusions. Hallucinations. Clinical anxiety. Antisocial behaviours / mood.

Details of ongoing screening or health checks or health promotion

Advocacy arrangements

Description

Give brief detail of any existing DoLs in place

Function details

Communication issues

Breathing

Eating/Drinking/Nutrition

Elimination details

Assessment information

About the person being assessed

General practitioner details

Dentist details

Medical information

Mental Health

Advocacy arrangements

Function details

Footcare

Vaccination status