Your Details

 * Required Fields

Title *

Mr Mrs Miss Ms Please Select  

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 *

Date of injury *

Your Height *

Your Weight *

Do you work? *

Full Time
Part Time
Don't work

Your Occupation 

Do you live alone?*

Yes No

If No, Who lives with you?

Partner
Other Adult
Child

Funding

Is your funding from/by:

Social services
Private
I L F
Other
Direct payments

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)

For what dates do you need a carer? *

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

If Other, Please specify:

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

If Other, Please specify:

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

If yes, how often:

Moving/Handling

Do you use:

Hoist
Standing Transfer
Sliding Board
Other (Please Specify)

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:

Male

Prefer
Essential

Female

Prefer
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

If yes, please describe

Additional information

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

Declaration of correct information 

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

Today's Date *

dd/mm/yy