Communication And Care Cues Template printable pdf download

Communication And Care Cues Template

Affix Carer label here

Surname:____________MRN: _____________

Given Names: __________________________

Date of Birth: ____/____/____Sex: __________

Affix Patient Label here (to be kept in Progress

Communication and Care Cues

Notes)

CARER

of Patient TO COMPLETE:

We know that Carers have information that you would like hospital staff to know to enable us

to provide better care for your relative/friend. Can you please share this information with us

by taking a few minutes to complete this form?

1. Does the patient have any communication difficulties (eg can’t say what they may want

to, can’t understand etc)?

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2. How does the patient normally move about (eg by themselves, with walking stick or

walking frame, holding on to the furniture etc)?

3. Does the patient wear any artificial aids (eg dentures, hearing aid, glasses, limbs etc)?

4. What are the usual hygiene habits (eg showering/bathing, shaving, toileting, continence,

denture management etc)?

5. Are there any special food or drink requirements or likes/dislikes (eg allergies,

consistency, religious, milk/sugar etc)?

6. What are the usual sleeping habits (eg bed time, waking time, pillows, blankets, position,

night caps, settling routines etc)?

Does the patient SMOKE

YES [ ]

NO [ ]

Does the patient drink alcohol regularly

YES [ ]

NO [ ]

Name & relationship

of person completing form:………………………………………………………………………….

Date:……………….

CATALOGUE NUMBER 09829

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Communication And Care Cues Template