ABBEYFIELD STRATHAVEN AND DISTRICT SOCIETY LTD

Resident’s Medical Form

Private and confidential

This form aims to provide the Application Sub-committee with information about your health and well-being. It will help the Abbeyfield Strathaven and District Society to decide whether Abbeyfield House is the right place for you and to make sure you are properly looked after if you move in.

Many residents have visits from district nurses, personal carers or home helps, for instance, and some use different aids and adaptations.

It is important that your answers to the following questions are as clear and accurate as possible so that we can ensure that the services you need can be provided. Use the space at Question 15 to add any information you think might help.
I.	Surname ………………………………………………..
 2.      Christian name(s)    ……………………………………                
	 3.      Date of Birth:……………………………	                                            Telephone Number: …………………              
	4.       Address:…………………………………………………………………………………………….     
	           …………………………………………………………………………………………………………                                         
5.	Have you been treated in hospital or as an outpatient within the last 2 years?	                    YES/NO	
         
           If yes, what for?  ……………………………………………………………………………                                                       
	
	What treatment did you have?  ……………………………………………………………
                                              
6.	Have you been visited at home by the District Nurse within the last year?	                                    YES/NO	
	
           If yes, why?  ………………………………………………………………………………
                                                          
7.	Do you have any health problems at the moment?				                    YES/NO
	
          If yes, please give details ................................................................................                                                  
	8.	      Are you taking any medicines or tablets, or using an inhaler, ointment, cream or other
	preparation?		                                               YES/NO
If yes, please give details below:
Name of Medicine 	 What it is for	How often you should take/use it
           ……………………	……………………..	……………………….
	……………………	……………………..	………………………
	……………………	……………………..	……………………….
	……………………	……………………..	……………………….
	9.       	 If you take medicines, do you use a memory box or other piece of equipment to help you?	     YES/NO  
            If yes, what is it?   ……………………………………………………………… 
10.	 Do you use a walking aid such as a walking stick (one or two?) or a walking frame? Please give details ………………………………………………………………………………………
11. 	Do you use a white stick?          YES/NO
12.	Do you use a wheelchair?          YES/NO
	If yes, is it self-propelled or pushed by a helper?  ………………………………….

13.	Do you use any special medical equipment, such as an artificial limb or colostomy bags?          YES/NO
	
            If yes, please give details ……………………………………………………………………………………………………….

14.	Do you have a special diet (e.g. Vegetarian, Kosher, or Diabetic?)   If so, please give details 
	
	………………………………………………………………………………………………………………………………………………..

15.	DO YOU SMOKE?  …………..                                                                                                                         YES/NO

16.      Please use this space to tell us anything else about your health which you would like us to know

	…………………………………………………………………………………………………………………………………………………

	…………………………………………………………………………………………………………………………………………………

17.	Name of your GP:  …………………………………………Telephone No: …………………………………………………

	Address:  …………………………………………………………………………………………………………………………………

	………………………………………………………………………………………………………………………………………………..

	For how long has he/she been your GP? …………………………………………………………………………………

18.	National Insurance Number (if known):  ………………………………………………………………………………...

	It may be helpful for the society’s medical adviser to ask your GP about your health.  This can only be done with your permission.  If you will allow this, please sign the following note:

	I permit the medical adviser to the Abbeyfield Strathaven and District Society to request information regarding my health from my General Practitioner.

	Signature …………………………………………………………………………………

	Name …………………………………………Date  …………………………………..

	The information given in this form is, to my knowledge, correct.

	Signature  ………………………………………Date  …………………………………..