Name I like to be called:

We like you to provide your full name but also the name you like to be called within the Home.

Where I live:

The area (not the address) where you live and how long you have lived there. Why it might mean something to you.

Carer/the person who knows me best:

This may be a spouse, relative, friend or carer.

I would like you to know:

Include anything you feel is important and will help staff to get to know and care for you, e.g. I have dementia, I have never been in hospital before, I prefer female carers, I am left-handed, I am allergic to …, other languages I can speak. These should be things that make you...you.

My life so far (family, home, background and treasured possessions):

Please include a place of birth, your education, marital status, children, grandchildren, friends and pets. Any religious or cultural considerations.

Current and past interests, jobs and places I have lived:

Include career history, voluntary experience, clubs and memberships, sports or cultural interests.

The following routines are important to me:

What time do you usually get up/go to bed? Do you have a regular nap or enjoy a snack or walk at a particular time of the day? Do you have a hot drink before bed, carry out personal care activities in a particular order, or like to watch the news at 6pm? What time do you prefer to have breakfast, lunch and evening meal? We can work out how we can accommodate these things within the framework of our Home.

Things that may worry or upset me:

This should include anything you may find troubling, e.g. family concerns, being apart from a loved one, or physical needs such as being in pain, constipated, thirsty or hungry. List environmental factors that may also make you feel anxious, e.g. open doors, loud voices or the dark.

What makes me feel better if I am anxious or upset?

Include things that may help if you become unhappy or distressed, e.g. comforting words, music or TV. Do you like company and someone sitting and talking with you or do you prefer quiet time alone?

My hearing and eyesight:

Can you hear well or do you need a hearing aid? How is it best to approach you? Is the use of touch appropriate? Do you wear glasses or need any other vision aids?

How we can communicate:

How do you usually communicate? E.g. verbally, using gestures, pointing or a mixture of both? Can you read and write and does writing things down help? How do you indicate pain, discomfort, thirst or hunger? Include anything that may help our staff identify your needs.

My mobility:

Are you fully mobile or do you need help? Do you need a walking aid? Is your mobility affected by surfaces? Can you use stairs? Can you stand unaided from a sitting position? Do you need handrails? Do you need a special chair or cushion, or do your feet need raising to make you comfortable? What physical activity do you take?

My sleep:

Include usual sleep patterns and bedtime routine. Do you like a light left on or do you find it difficult to find the toilet at night? Do you have a favoured position in bed, special mattress or pillow?

My personal care:

Please could you make a list of your usual practices, preferences and level of assistance required in the bath, shower or other. Do you prefer a male or female carer? Do you have preferences for brands of continence aids, soaps, cosmetics, toiletries, shaving, teeth cleaning or dentures? Do you have particular care or styling requirements for your hair?

How I take my medication:

Do you need help to take medication? Do you prefer to take liquid medication?

My eating and drinking:

Do you need assistance to eat or drink? Can you use cutlery or do you prefer finger foods? Do you need adapted aids such as cutlery or crockery to eat and drink? Does food need to be cut into pieces? Do you wear dentures to eat or do you have swallowing difficulties? What texture of food is required to help – soft or liquidised? Do you require thickened fluids? List any special dietary requirements or preferences including being vegetarian, and religious or cultural needs. Include information about your appetite and whether you need help to choose food from a menu.

Other notes about me:

This gives you a space to include any additional details about you that are not listed above and help to show who you are, e.g. favourite TV programmes or places, favourite meals or food you vehemently dislike, significant events in your past, expectations and aspirations you have.

You may also want to Indicate here any advance plans that you have made, including the person you have appointed as your attorney, and where health and social care professionals can find this information.