new patient form Resident’s First Name Resident’s Surname malefemale Date of Birth Ethnicity Date of Admission to care Home Admitted from Home or Hospital Hospital Registered Copy of Hospital Discharge Letter if applicable attachedyesno Medication How many days supply of medicines does the new resident have Resident’s Next Of Kin Details Next of Kin’s Name Relationship to Resident Next of Kin’s Current Address Telephone Mobile Number Has consent been given for medical information to be discussed with Next of Kin or any other persons? yesno Does Resident Have a Power of Attorney? yesno Emergency Contact Details Name Relationship to Resident Current Address Telephone number Mobile number Resident’s Wishes Consent to share Enhanced Summary Care Record yesno Does Resident Have Living Will? yesno or Advanced Care Plan? yesno Anticipatory Care wishes known yesno Care Plan with details attached yesno DNAR in Place yesno End of Life Wishes Known yesno Care Plan with details attached yesno Resident’s Assessment of Needs Mobility: Independentwalking aidsNeeds Assistance BedNeeds Assistance Bed Continence: ContinentUrinary Incontinence – wears padscatheter in-situFaecal Incontinent Cognition: No ImpairmentSome confusion1-2 words onlyNo meaningful interaction Communication: Speaks ClearlySpeech Difficult to UnderstandUnable to communicate Verbally Hearing Impairment: No ImpairmentHearing DifficultiesDeaf Sight Impairment: No ImpairmentMild Sight Impairment Significant SightImpairment Blind Describe Resident’s Mood Pressure Area Issues Weight: Any Other Issues: Height: Blood Pressure: Pulse: Oxygen Sats: Respiration Rate: Smoking Status: Non-smokerEx-smoker Current smoker? how many cigarettes per day Alcohol Status:Non-drinkerDrinks Alcohol Dinks Alcohol? how many per day