Nationwide Live-in Care Services

International Holiday Care

Client Registration Form

Client Registration form

Your Details

Title *

First Name *

Last Name *

Address *

Postcode *

Tel no * (with code)

Mobile no *

Fax no

Email *
(If you do not have an email address, or do not know your address then please use clients@origincare.com)

Sex *  Male Female

Date of Birth *

Nationality *

Level of Spinal Injury *

Year of Injury *

Your Height *

Your Weight *

Do you work? *  Full Time Part Time Don't work

Do you live alone? *  Yes No

Funding

Is your funding from/by: Social services Private NHS Direct Payments Other (please give details)

Personal care assistance requirements

Which sort of live-in option do you require? * Respite Carer(s) (normally for short-term cover and holiday but can be an ongoing series) Private permanent carer(s) (introduction of carers to be employed by you) Fully Managed Care (long-term cover involving all carers, permanent & respite, employed by us to work on your behalf)

If you know the dates you need a carer please enter them below. If you do not have specific dates, please leave blank.

Start Date

End Date

Do you need your assistant to drive? Essential Preferable No

For which of these tasks do you need assistance? Getting up Going to bed Washing Dressing Feeding Shaving Cooking Cleaning Shopping

Bladder Management Condom with leg bag In-dwelling catheter Supra-pubic catheter Need for expression Other

Is bowel/bladder management carried out by: Your Carer A District nurse Other

Bowel Management Suppositories Digital stimulation/check that bowel is empty Enema Other

Routine of bowel evacuation

e.g. daily/two daily

Carried out by:  Carer District Nurse Other

Do you use  Bed Shower chair/toilet

Personal Hygiene

Which method of washing do you use?  Showering Bedbath Bathing

How often

Do you require turning at night?  Yes No

Moving/Handling

Do you use:  Hoist Standing transfer Sliding board Other

Do you suffer from / are you prone to:  Pain Autonomic dysreflexia Spasm Severe cold Low blood pressure Skin problems

Do you use a ventilator  Yes No

Do you want your carer to be

Please pick *  Male (Prefer) Male (Essential) Female (Prefer) Female (Essential) Don't mind

Medical conditions

Other than the spinal injury itself, do you have/have you ever had any other illnesses or medical conditions?  Yes No

Additional information

Anything which may affect your choice of carer (e.g. if you have pets) or any forthcoming holidays.

Declaration of correct information

(Please Tick) *  I hereby confirm that to the best of my knowledge, the above statements are true and correct

Please leave this field empty.

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