An Introduction to me
Please complete as much of this information as you can to help the critical care team to provide the best possible care for your relative or friend
Personal details:
My preferred name:
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My age:
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My religion:
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My dietary requirements:
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My communication needs:
e.g. hearing aids, speech difficulties, glasses
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My next of kin:
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Relationship to me:
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Next of kin contact numbers:
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The names of people important to me – family, friends and pets:
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My health:
My known allergies:
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My medical health:
e.g. asthma, dementia, any recent changes
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My mental health:
e.g. anxiety, depression, any recent change
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My sleeping pattern:
e.g. when I go to sleep, when I wake up, if I have disturbed sleep or take naps
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What is most important to me:
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My likes and dislikes:
Favourite TV or radio programmes/ channels:
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What I most enjoy doing:
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What I dislike – my pet hates:
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My last known occupation:
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What I’m most proud of:
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Food and drink:
Likes
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Dislikes
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My daily life:
I can do the following things independently:
- Wash
I prefer to have a:
- Shower
- Bath
- Other ………………………………
- Shave
- Dress
- Go to the toilet
- Eat my meals
- Move around my home
- Walk up stairs
Mobility aids:
e.g. walking stick, wheelchair
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Any extra information about the things I can do:
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Any extra information about me that would help the critical care team:
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This has been completed by:
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