Application Form Application Form Step 1 of 6 16% Service Interested In(Required)Home CareDay CentreNursing HomeMeals on Wheels (Minchinhampton only)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 NoIs your GP willing to retain you as their patient when you enter residential care?(Required)YesNoNot ApplicableWill your care be funded(Required)PrivatelySocial Services / NHS Day Centre Applicants OnlyIs Day Centre transport required?(Required)YesNoPreferred Day Centre days(Required)MondayTuesdayWednesdayThursdayFriday Home Care applicants onlyPlease tick your current requirements.(Required)Household tasksPersonal careSitting serviceMeals on wheelsDo you have any professional help with daily living?(Required)YesNoIf yes, is this from:(Required)District NurseA Home Care worker or agencyPrivate helperDay CentreOtherIf applicable, please name the agency that assists you.(Required) Eating and DrinkingDo you have any dietary requirements?(Required) Yes No Please provide more details(Required) Do you need assistance with meals?(Required) Yes No Please provide more details(Required) Continence CareDo you require any help with continence care?(Required) Yes No Other Please provide more details(Required) Continence CareDo you require help with personal care?(Required) Yes No Do you require help with washing?(Required) Yes No Do you require help with dressing?(Required) Yes No Do you require assistance with mobility?(Required) Yes No 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 No Other Please provide more details(Required) Do you require any specialist equipment?(Required) Yes No Other Please provide more details(Required) SightDo you wear glasses?(Required) Yes No Other Do you have a vision related diagnosis?(Required) Yes No Other HearingDo you have problems with your hearing?(Required) Yes No Other Do you use hearing aids?(Required) Yes Yes, but with hearing aids No Other Communication and MemoryCan you express yourself verbally?(Required) Yes No Do you have a memory problem?(Required) Yes No Do you have a problem with confusion?(Required) Yes No Approximate memory diagnosis date? MM slash DD slash YYYY Support service input?(Required) Yes No SleepPlease describe your sleep pattern Do you require any specialist equipment or support?(Required) Yes No Please provide more details(Required) General QuestionsDo 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 No 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 No 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 requiredPlease 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 hobbiesIf you are currently in hospital, please give detailsDo you consent for your photograph being taken for use on our Digital Care Plans inline with our Privacy Policy?(Required) Yes No Do you consent for your photograph being used for marketing and promotional use inline with our Privacy Policy?(Required) Yes No I would like to hear more about the work of Horsfall House through your newsletters.(Required) Yes No 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. SignedName(Required) Date(Required) MM slash DD slash YYYY Relationship to applicant if signed on their behalf CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
