Client_Personal_Information_form.docx -

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Client Personal Information Form Please return to Paid Carer/Organisation Name Paid Carer/Organisation Address To be completed by/with the Client Personal Details Full Name Mr/Ms/Miss/Mrs Male / Female Date of Birth Name you like to be known by Address Telephone Number Home Mobile Postcode How long have you lived at this address? What is your National Insurance Number? Do you have a Key Safe? Yes No Number Next of Kin This person will only be contacted, or information divulged to them, in the event of an emergency. Full Name Address Telephone Number Home Mobile Postcode Relationship Keyholder? Yes No Are you in contact with them? Yes No -1- Client Personal Information Form What is your ethnicity or descent? White European Black African Bangladeshi White Other Black Other Chinese Black Caribbean Indian Other Black British Pakistani Refused / Not Known Health NHS Number Do you have any disabilities we should know about? Yes No Details Do you need information in a different format or language? Yes No Specify (e.g. large print, audio, language) GP Name Address Telephone Number Keyholder? Yes No Consultant N/A Name Address Telephone Number CPN N/A Community Practice Nurse Name Address Telephone Number -2- Client Personal Information Form Keyholder? Yes No -3- Client Personal Information Form Care Manager N/A Name Address Telephone Number Keyholder? Yes No Social Worker N/A Name Address Telephone Number Keyholder? Yes No Are you currently undergoing treatment or receiving medication? Yes No Specify types and dosage (e.g. 2x paracetamol 500mg 2 x a day) Are you currently registered as an organ donor? Yes No Details – in an emergency where will we find the card? (eg in your wallet) Cultural and Religious Needs How would you define your spirituality/religion Atheist Catholic Jewish Agnostic Christian other Muslim Buddhist Hindu Other please define Sikh Refused / Not Known Do you have any religious needs Yes No e.g. Food & worship requirements etc -4- Client Personal Information Form Contact What contact do you have with… Family? Friends? Other? Any other useful further information I give permission for my Paid Carer to share relevant information with other organisations/ individuals where it is beneficial/necessary for my health or welfare. Signed Date Applicant -5-