Medicine of Later Life - Cantwell Spillane

Cantwell Spillane

Homepage
Prescriptions
- Long-term Prescriptions
- Combined Oral Contraceptive Prescriptions
UPLOADS
- Update your details
- Medicine of Later Life
FLU&COVID VACCINES

Homepage
Prescriptions
- Long-term Prescriptions
- Combined Oral Contraceptive Prescriptions
UPLOADS
- Update your details
- Medicine of Later Life
FLU&COVID VACCINES

MEDICINE OF LATER LIFE QUESTIONNAIRE

* Indicates required field

Your own details (person filling form) *

Name of Patient *

Address of patient *

DOB of Patient *

What are your main concerns *

Please tick any that apply *

The patient goes regularly to the GP Rarely goes to GP not well known to surgery The Public Health nurse is involved Goes to hospital appointments Is under the Medicine for the Elderly Team Has a homecare package Has been assessed at home by the integrated care team Has been referred to palliative care previously

Name(s) and contact details of ALL Next of Kin *

Name(s) and Contact Details of Assigned Carers *

Who does the patient live with have they regular visitors *

Describe family organisation, how many children, who is involved, are there any interpersonal difficulties *

Does the patient know you are contacting us? *

Yes No

Has the patient any concerns? (please tick any that apply) *

Physical Health Mental Health Memory Issues Social Issues Vulnerable Patient has no concerns

What are main concerns NOK, Family Carers *

Physical Health Mental Health Memory Issues Social Issues Vulnerable

Is the patient managing at present *

Yes No

Is the patient on any of the following medications (see last box if you cannot answer) *

Anti-depressants Relaxers Any tablets for mental health issues Tablets for dementia Pain killers Tablets for overactive bladder Multiple medications Are the medications blister packed Is the patient experiencing medication side effects? Is the patient in pain? I dont know anything about the patients medications

Has the patient any problems with *

Hearing Vision Nutrition Bowel Bladder Mobility Recurrent Falls Dizziness The patient is a palliative care patient

Are there issues in the home with *

Cooking and heat, hob oven risk of burns Water electricity Security leaving doors open wandering etc Risk of deliberate self harm Concerns re elder abuse Concerns re driving Concerns re delerium or psychosis

Have the following forms/documents/assessments been completed *

Enduring power of attorney Assessment of capacity to make decisions A will Carers forms Home assessment by Occupational Therapy Home assessment by Integrated care team Plans for respite Plans for longterm care Driving assessment in car driving assessment

Submit

Contact Us
133 St Peter's Rd, Walkinstown, D12XN9F
Ph switch 4504168 Fax 4783175

23 Old Bawn Way, Tallaght, D24 TKP0
Ph switch 4504168

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