SLIDE 1 Please Note: This view was saved in October 2018. Elements of this page may have been
updated, added or removed. If client data is on this screen, it is purely fictitious in nature and was taken from our test system. Please excuse the informality and incorrectness of this incomplete and fictitious data.
InfoAnywhere Client Profile
Client Overview
Client Name: TestPerson Palliative #2650
First Contact Date:
Oct 27
Assessment Date:
Oct 27
Programs / Services Requested:
Anticipatory Grief Groups Anticipatory Grief Indiv Bowmanville Wellness Camp Caregiver Support By Volunteer Day Respite External Referral Grief And Bereavement Groups Grief And Bereavement Indiv Outreach After Hours Outreach Business Hours Overnight Respite Resident Accompaniment Rostered Test Rostered Test2 Spiritual Health Transportation Visiting Accompaniment Wellington Wellness
* This field must be filled out at time of referral / assessment for proper MIS reporting *
Programs / Services Involved:
N/A
Service Notes:
None Recorded
Personal Information
Sal: First Name.: TestPerson Middle Name: Last Name: Palliative Address: City: Choose One Postal: Do Not Send Mailings: Primary Contact Method: Choose One Address notes / buzzer code, etc: Closest Intersection: LHIN NUMBER: Choose One Telephone: Tel 2: Email:
2018 2018
SLIDE 2
Gender: Choose One Date Of Birth: Age: Unknown Health Card: VC: MRN: Ethnicity: Unspecified Health Conditions (OHRS Stat): None Religion: Unspecified Marital Status: Primary Language: Unspecified
Referral Information
Special Considerations: None Recorded
Situational Information
LifeLimiting Diagnosis: Choose One Client Aware Of Diagnosis: Unknown Complexity: Unspecified Service / Privacy Agreement Last Signed: Service / Privacy Agreement Renewal: Hospice Physician Role: Unknown Prognosis at service start: Unavailable Current PPS: Unspecified Diagnosis Details & History: None Recorded Medical Allergies: None Recorded Diet Information:Available Options: None, Allergy Eggs, Allergy Fish/Shellfish, Allergy Dairy, Allergy Nuts, Allergy Mushrooms, Allergy Soy, Allergy Sulfites, Allergy Wheat/Gluten, Diabetic, Taking Food Supplements, Kosher, Lactose Intolerant, Little Appetite, No Dairy, Swallowing Difficulty, Soft Diet, Thickened Fluids, Tube Treatment Plan:Available Options: None, Chemotherapy, Radiation, Surgery, Palliation, Other,
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Feeding, Vegetarian, Vegan, Other, Physical Symptoms: Available Options: None, Aphasic, Bedridden, Constipation, Delirium, Diarrhea, Fragile, Hearing Impaired, Incontinent, Nausea, Non Ambulatory, Obesity, Paralysis, Physical Pain, Restlessness, Seizure Activity, Shortness of Breath, Swelling, Vision Impaired, Vomiting, Weakness, Other (details below), Symptoms Management: Available Options: None, Assistive Devices, Augmented Communication, Cane, Catheter, Colostomy, Crutches, Hearing Aid, Hoyer Lift, Incontinence Products, Oral Medication, Oxygen, Pain Patch, Pain Pump, Physiotherapy, Special Mattress, Tensor, Walker, Wheelchair, Other (details below), Other Organizations Involved With This Client: Available Options: CCAC, VON, Physical Situation: None Recorded Feelings, Attitude and Emotional Status: None Recorded Coping Methods, Socialization: None Recorded Support Services: None Recorded Smokers/Substance Abuse: None Recorded
Environmental Conditions & Information
Smokers In The Home: Unknown Animals In The Home: Unknown Stairs: Unknown Living Arrangements: Available Options: Alone, Child/Children, Friend(s), Parents(s), Partner, Relative(s), Sibling(s), Spouse, Other(s), Grandparent(s), Grandchild(ren), Care Partner, Institution, Dwelling: Home Others In Household: None Recorded Notes: None Recorded
Client Requests For Volunteer
Preferred Gender: No Preference Faith For Spiritual Support: Choose One
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Aboriginal Buddhist Catholic Hindu Islam Jewish NonReligious Not Requested Other Protestant Sikh Preferred Language of Service: Choose One Afrikaans Arabic Belarusian Bengali Calabrese Cantonese Czech Dutch English Esperanto Esperanto Estonian French German Greek Gujarati Hindi Hungarian Italian Japanese Korean Lithuanian Mandarin Marathi Ojibwa Polish Portuguese Punjabi Pushto Romanian Russian Sinhalese Slovak Spanish Swahili Tamil Teluguge Thai Twi Ukrainian Urdu Vietnamese Zulu Cultural Background: Choose One Aboriginal Aboriginal Miqmak Afghanistani African Bangladesh Caribbean Chinese Chinese China
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Chinese Hong Kong Chinese Taiwan Dutch Eastern European English/Irish/Scottish/Welsh French French Canadian German Indian Iranian Iraqi Italian Japanese Korean Mexican Other Asian Pakistani Philippino Portuguese Russian Spanish Sri Lankan Thai Unknown Vietnamese Available For Service: (choose all applicable) Sun Mon Tue Wed Thu Fri Sat 9amNoon Noon3pm 3pm6pm 6pm9pm Overnight Respite Select All Select None Interests, Hobbies, Work Experiences, Memberships, Traits, History, etc.: None Recorded Popular hobbies include: Carpentry Guitar Making Luthier Other Requirements: None Recorded
Other
Do Not Resuscitate (DNR): Preferred Location Of Death: Unknown DNR Number & Date: DNR Location: Plans In Case Of Emergency: None Recorded Plans At Time Of Death: None Recorded Funeral Plans: None Recorded Will Location & Details: None Recorded Advance Care Planning: None Recorded Additional Notes: None Recorded Priority Notes:
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