Office Completions
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Office completions
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1)
Please tell us about the patient:
Full Name of Patient:
Patients Date of Birth:
Is the patient living or deceased:
If deceased, state date of death:
2)
Has the patient
ever
been detained under Section 2 of the Mental Health Act 1983? (If it is relevant, how long ago this occurred?)
Yes
No
Don't Know
3)
If you have answered 'Yes' to this question please could you give us some further details, such as the date the patient was sectioned and details of the incident leading to this:
4)
Please state the Patient's past and current medical history and physical illnesses in particular whether the patient has suffered from Diabetes, Epilepsy, Parkinson's Disease, Cancer, Arthritis, Stroke etc (please give dates where possible of diagnosis):
5)
Address of Current/past Care Home(s)
6)
On what date did the patient become a resident of the above Care Home?
7)
Could you please give an estimate of how much has been paid to date to the Care Home/s to provide for the care of the patient? £
8)
How much if any, has been paid by a deferred payment? £
9)
Please tell us the patients GP details:
GP details before entering the home:
GP details whilst in the home:
10)
Please tell us the patient's home address
prior
to going into a care home?
11)
Please indicate whether the Care Home is one of the following:
a residential home
a nursing home
a residential home for elderly mentally infirm
a nursing home for the registered elderly infirm
12)
If the Care Home is a dual registered home, Does/did the patient have a:
It is very important you answer this question, if you are unsure please telephone the Care Home where the patient is or was to find out the answer.
a residential bed
a nursing bed
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