Accident & Emergency Grab Sheet
We will use this to ensure all of our client records are up to date.
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Client's full name: *
Client's preferred name (if different from above):
Client's disabilities/diagnoses: *
Does the client have Down syndrome? *
Client's date of birth: *
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Client's postal address: *
Client's Next of Kin/emergency contact and their relationship to the client: *
Next of Kin/emergency contact's telephone number: *
Next of Kin/emergency contact's email address: *
Next of Kin/emergency contact's postal address (if different from client's):
Next of Kin's preferred method of communication (please tick all that apply): *
Required
Secondary contact and their relationship to client (eg, mum or dad if separated):
Secondary contact's telephone number:
Secondary contact's email address:
Secondary contact's postal address:
Secondary contact's preferred method of communication (please tick all that apply): *
Required
Name of client's carer (if different from anyone mentioned above):
Carer's contact number (if different from anyone's mentioned above):
Name of client's GP: *
Client's GP's address: *
Client's GP's telephone number: *
Name of client's LD Nurse:
Client's LD Nurse's telephone number:
Name of client's social services worker: *
Social services worker's telephone number: *
Medication history / pre-existing medical conditions (eg epilepsy, diabetes, high blood pressure). If epilepsy, please describe the type of seizure: *
Regular medication: *
How medication is taken: *
Date of last tetanus:
MM
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DD
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YYYY
Date of first COVID-19 vaccine:
MM
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DD
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YYYY
Date of second COVID-19 vaccine (if known):
MM
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DD
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YYYY
Known allergies (incl. medication): *
Client's preferred method of communication: *
The best way to give information to client: *
The best time to give information to client: *
Method of expressing pain (eg crying, facial expressions, vocalisations): *
Additional health needs.       1. Hearing difficulties? *
If yes, please specify any additional equipment resources required to support the client:
Additional health needs.      2. Vision difficulties? *
If yes, please specify any additional equipment resources required to support the client:
Additional health needs.        3. Mobility - wheelchair user? *
If yes, please specify any additional equipment resources required to support the client:
Additional health needs.       4. Mobility - uses hoist? *
If yes, please specify any additional equipment resources required to support the client:
Additional health needs.    5. Mobility - any other mobility aids? *
Required
If yes, please specify any additional equipment resources required to support the client:
Special dietary needs (eg diabetic, gluten free, soft drinks, risk of choking, specialist equipment needed):
Keeping safe (eg bed rails, water temperature, wandering):
Likes (eg quiet room, personal item / possession):
Dislikes - which may lead to anxiety / behaviours (eg noises, specific items, needles):
Actions which may reduce anxieties:
Any additional information you'd like us to know:
Form completed by (full name): *
Date form completed: *
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