Specialist Live in Spinal Injury Care | Live in Care and Carers - Origin Care

Nationwide Live-in Spinal Injury Care Services Call Us 01524 34100

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Client registration form

Your details

Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City County Postcode

Phone(Required)

Email(Required)

Sex(Required)

Male

Female

Date of Birth(Required)

DD slash MM slash YYYY

Nationality(Required)

Level of Spinal Injury(Required)

Year of injury(Required)

Funding

Is your funding from / by(Required)

Social services

Private

NHS

Direct payments

Other

Personal care assistance requirements

Which sort of live-in option do you require?(Required)

Repite 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 & repite, employed by us to work on your behalf

Start date

MM slash DD slash YYYY

End date

MM slash DD slash YYYY

Do you need your assistant to drive?(Required)

Essential

Preferable

No

For which of these tasks do you need assistance?(Required)

Getting up

Going to bed

Washing

Dressing

Feeding

Shaving

Cooking

Cleaning

Shopping

Bladder management(Required)

Condom with leg bag

In-dwelling catheter

Supra-pubic catheter

Need for expression

Other

Is bowel / bladder management carried out by(Required)

Carer

District nurse

Other

Bowel management(Required)

Suppositories

Digital stimulation / check that bowel is empty

Enema

Other

Routine of bowel evacuation

Frequency(Required)

Once per day

Two times a day

Three times a day

Carried out by(Required)

Carer

District nurse

Other

Personal hygiene

Which method of washing do you use?(Required)

Showering

Bedbath

Bathing

How often?

Moving & handling

Do you use:(Required)

Hoist

Stranding transfer

Sliding board

Other

Do you suffer from / are you prone to:(Required)

Pain

Autonomic dysreflexia

Spasm

Severe cold

Low blood pressure

Skin problems

Do you use a ventilator?(Required)

Yes

No

Do you want your carer to be…

Please pick(Required)

Male (Prefer)

Male (Essential)

Female (Prefer)

Female (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?(Required)

Yes

No

Additional information

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

Where did you hear about us?(Required)

Please tell us where you heard about us(Required)

Declaration of correct information

I confirm the info given are correct and that I have read the Privacy Statement(Required)

Please tick, to confirm and continue

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