Bexley Self Assessment Form

*Family Name:

*Forename(s):

*Title: Please Select Brother District Nurse Doctor Lady Lord Major Master Miss Mr Mrs Ms Professor Reverend Sister

*Gender: Please Select Male Female Unknown

*Date of Birth:

*Religion: Please Select Buddhist Christian Gujarati Hindu Jehovah witness Jewish Muslim No Religion Roman Catholic Sikh Taoist Prefer not to say Other Religion - specify

*Permanent Address:

Current Address (if appropriate):

*Telephone - Permanent Address:

Telephone - Current Address (if appropriate):

Email Address:

*Type of Accommodation : Please Select Permanent Temporary

*Tenure: Please Select Council Lives rent free Guest Housing Association Lodger No fixed abode Owner Occupier Owns Outright Owns with mortgage or loan Pays part rent part mortgage Patient Owned (not resident) Living with Relative Private Rented Temporary Accommodation Temporary Accom-Asylum Seeker OLA Unknown

If rented, what is the situation?: Please Select Housing Association Private rental Lodgings

Ethnicity: Please Select White-British (non-Irish) White Irish White - Other Mixed - White & Asian Mixed - White & Black Caribbean Mixed - White & Black African Mixed - Other Asian - Indian Asian - Pakistani Asian - Bangladeshi Asian - Other Black or Black British - Carribbean Black or Black British - African Chinese Other

Preferred first language: Please Select English Punjabi Albanian Czechoslovakian Polish Cantonese Turkish Spanish French Arabic Gujarati Serbo / Croat Somalian Romanian Russian Vietnamese Slovakian Portuguese Farsi Kurdish Tamil Bengali Other - Please Specify

Interpreter Required?:
Yes       No

Which of the following describes your situation the best: Please Select N/A Asylum Seeker Dementia Learning Disability Mental Health Vulnerable People Physical Disability Welfare Benefits Dual Sensory Loss Frail/Temporary Illness Hearing Impairment Substance Misuse Visual Impairment Other - Please Specify

Other:

Do you consent to information being shared?: Yes       No

If no, please give the reason:

Are you completing the self assessment questionnaire for yourself?: Yes       No

If No, please provide your relationship with service user:

Is the service user aware of this self assessment?: Yes       No

Next of Kin

Name:

Relationship of Next of Kin:

Address:

Telephone:

Main Carer

Name:

Address:

Telephone:

Emergency Contact

Name:

Address:

Telephone:

G.P.

Name:

Address:

Telephone:

Who lives with you?: Please Select Adults Only Living Alone Household with Children Shared Accommodation

If you live with somebody:

Does the person(s) you live with also have a disability/illness?: Yes      No

Does the person(s) you live with work or study full time: Yes      No

Is the person(s) you live with under the age of 16?: Yes      No

If you live with children please give their names, ages and schools that they attend:

Do you claim any of the following disability benefits?:

Mobility Component:

Disibility Living Allowance : No      Yes - Low     Yes - Middle      Yes - High

War Pensioner: No      Yes - Low     Yes - High

Care Component:

Disibility Living Allowance : No      Yes - Low     Yes - Middle      Yes - High

War Pensioner: No      Yes - Low     Yes - Middle      Yes - High

Attendance Allowance: No      Yes - Low     Yes - High

Pension Credit: No      Yes

Incapacity Benefit: No      Yes

Physical Health

Q1. Do you have a long term health condition or disability?: Yes      No

If 'Yes', does your condition mean you need someone with you most of the day?:
Yes      No

Q2. Have you had a hospital stay in the last six months?: Yes      No

Q3. Are you receiving specialist support as a hospital out/in patient?:
        Yes      No

Q4. Has your condition deteriorated rapidly in the last two months?:
        Yes      No

Q5. Do you ever experience episodes of breathlessness?:
        Yes      No

Q6. Can you chew and swallow your food and/or drink without assistance?:
        Yes      No

Q7. Can you see without assistance? (assistance does not include using glasses):
         Yes      No

If 'Yes', go to Question 8

If 'No', are you registered blind or partially sighted?: Yes      No

Do you need additional help now because of your vision?: Yes      No

Q8. Can you hear without assistance?: Yes      No

If 'Yes', go to Question 9

If 'No', are you registered deaf or partial hearing loss?: Yes      No

Do you need additional help now because of your hearing?: Yes      No

Mental Health

Q9. Do you receive treatment for confusion?: Yes      No

Q10. Do you receive treatment for memory loss?: Yes      No

Q11. Do you receive treatment for stress and/or anxiety?: Yes      No

Choice & Control

Q12. Can you communicate without assistance?: Yes      No

If 'Yes' go to Question 13

If 'No', do you need help because English is not your first language?: Yes      No

If 'Yes', which language do you speak?:

If 'No', do you need help because you have difficulty with speaking or understanding?: Yes      No

Q13. Can you manage to protect yourself from others who may, for example, take your money or possessions, hurt you or not look after you properly?:
        Yes      No

If 'Yes', go to Question 14

If 'No', do you think you can manage if you had an emergency system that summoned help?: Yes      No

Q14. Can you manage to understand and/or make decisions without assistance?:
        Yes      No

If 'Yes', go to Question 15

If 'No', do you need help: Some of the day      All of the day

Q15. Can you control your actions and mood?:
        Yes      No

If 'Yes', go to Question 16

If 'No', when you cannot control your actions and mood, are you aggressive and is this due to a physical or mental health condition?: Yes      No

Q 16. Are you able to get out of your house independently?:
        Yes      No      Sometimes need help

If 'Yes', go to Question 17

If 'No', do you need help getting in and out of the house?: Yes      No

Why do you now need help?:

Personal Care

Q17. Are you able to use the toilet independently? (This may be practical support, prompting or supervision): Yes      No      Sometimes need help

If 'Yes', go to Question 18

If 'No', do you think you could manage with simple equipment such as a raised toilet seat to make it easier to get on/off the toilet or commode if there is someone at home who can assist you to empty it?:

Raised Toilet Seat: Yes      No

Raised toilet seat with surround: Yes      No

Commode: Yes      No

Please state:

Height:     Weight:

If you answered 'Yes' for one of the options above, please go to Question 18

If you need further help, please indicate which describes your situation best:

I need someone to help me: Yes      No

I need support to use continence aids: Yes      No

I need help with stoma management: Yes      No

Why do you now need help?:

Q 18. Can you wash yourself? (This may be practical support, prompting or supervision):
        Yes      No      Sometimes need help

If 'Yes', go to Question 19

If 'No', do you think you could manage with any of the following equipment whilst washing?:

Long Handled Sponge: Yes      No

Perching Stool: Yes      No

Please state:

Height:     Weight:

If you need further help, indicate which describes your situation best:

I am in need of support to wash: Yes      No

Why do you now need help for washing?:

Q 19. Can you dress yourself? (This may be practical support, prompting or supervision):
        Yes      No      Sometimes need help

If 'Yes', go to Question 20

If 'No', do you think you could manage with simple equipment such as a stocking/sock aid?: Yes      No

Why do you now need help?:

Q20. Do you need help taking your regular medication? (This may be practical support, prompting or supervision): Yes      No      Sometimes need help

If 'No', go to Question 21

If 'Yes', how much help do you need?: All of the time      Some of the time

If you need help 'some of the time', do you think you could manage with a pill dispenser that can be filled with medication and prompt you to take it?:
Yes      No

Why do you now need help to take your medication?:

Q 21. Can you walk indoors independently?: Yes      No      Sometimes need help

If 'Yes', go to Question 22

If 'No', do you need help going up/down stairs?: Yes      No

Why do you now need help?:

Q 22. Can you get on/off furniture like a chair or a bed independently?:
        Yes      No      Sometimes need help

If 'Yes', go to Question 23

If 'No', what do you find difficulty with?:

Getting on/off chairs: Yes      No

Getting in/out of the bed: Yes      No

Why do you now need help?:

Q 23. Can you walk outside independently?:
        Yes      No      Sometimes need help

If 'Yes', go to Question 24

Why do you now need help?:

Q 24. Have you fallen in the last six months?: Yes      No

If 'No', go to Question 25

If 'Yes':

Did you injure yourself?: Yes      No

Did you fracture a bone?: Yes      No

Domestic Support

Q 25. Can you prepare simple meals independently?:
        Yes      No      Sometimes need help

If 'Yes', please go to Question 26

If 'No' or 'Sometimes need help', is this because?:

Unable to move around home independently: Yes      No

Need supervision or prompting: Yes      No

If you live alone please answer the following - what do you find difficulty with?:

Reheating chilled or frozen meals: Yes      No

Moving hot meals from preparation place to eating place: Yes      No

Would a simple aid like a trolley help?: Yes      No

Why do you now need help?:

Q 26. Can you keep the essential areas of your house clean?:
        Yes      No      Sometimes need help

If 'Yes', please go to Question 27

If 'No' or 'Sometimes need help', is this because?:

Unable to move around home independently: Yes      No

Need supervision or prompting: Yes      No

Why do you now need help?:

Q 27. Can you do your laundry?:
        Yes      No      Sometimes need help

If 'Yes', please go to Question 28

If 'No' or 'Sometimes need help', is this because?:

Unable to move around home independently: Yes      No

Need supervision or prompting: Yes      No

Medical condition and/or incontinence – high laundry needs: Yes      No

Why do you now need help?:

Q 28. Can you manage your money independently? This refers to making sure payments are made or you can access cash:
        Yes      No      Sometimes need help

If 'Yes', please go to Question 29

If 'No' or 'Sometimes need help', is this because?:

Need supervision or prompting: Yes      No

Why do you now need help?:

Q 29. Can you shop for basic items?:
        Yes      No      Sometimes need help

If 'Yes', please go to Question 30

If 'No' or 'Sometimes need help', is this because?:

Need supervision or prompting: Yes      No

Why do you now need help?:

Q 30. If you have solid fuel heating, can you light the fire?:
        Yes      No      Sometimes need help

If 'Yes' or if you do not have solid fuel heating, please go to Question 31

If 'No' or 'Sometimes need help', is this because?:

Need supervision or prompting: Yes      No

Why do you now need help?:

Wider Involvement

Q 31. Are you able to maintain or build friendships?:
        Yes      No      Sometimes need help

If 'Yes', please go to Question 32

If 'No' or 'Sometimes need help', is this because opportunities to mix with people are limited by my illness/disability?: Yes      No

Q 32. Are you able to take part in activities outside your home? This includes working, undertaking education and leisure:
        Yes      No      Sometimes need help

If 'Yes', please go to Question 33

If 'No' or 'Sometimes need help', is this because?:

Need supervision or prompting: Yes      No

What does this relate to?:

Work: Yes      No

Lesiure: Yes      No

Learning: Yes      No

Why do you now need help?:

Q 33. Are you able to carry out your caring or parental duties?:
        Yes      No      Sometimes need help      Do not have any duties

If you do not have any Caring or Parental duties, please proceed to submit.

If you do have duties and live with a partner, are they able to help?:
Yes      No      Do not live with a partner

Who do you care for?:

Children: Yes      No

Adult Relative: Yes      No

Why do you now need help?: