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Preparation for Self Management
Before we come out and see you, here is a simple questionnaire for you to complete in preparation for your home visit. This will help make sure you get the most out of your home visit.
Your Name
Mobile
Email
This section will help us understand where you want to focus for self management, and what we might need to do to support you to reach your goals.
I am most looking forward to
Getting more out of my Home Care Package
Choosing who comes into my home
Having greater choice and flexibility of services
Other
How I am feeling about different aspects of self management
I'm very worried
I'm nervous
I'm confident
Managing my own budget
I'm very worried
I'm nervous
I'm confident
Finding and scheduling my own workers
I'm very worried
I'm nervous
I'm confident
Understanding how it all works
I'm very worried
I'm nervous
I'm confident
How well I am coping in my current situation
Falling off the edge
Barely holding on
Holding on
Standing strong
Other
What are the concerns I want support for in my package?
My Health - tick all that apply
My hearing regularly causes me problems
My eyesight regularly causes me problems
My mood has negative impacts on my relationships with others and/or day to day life
I have concerns about my memory and/or how well I think
I have trouble sleeping
I get confused about what medication I need to take and when
I need help managing my medication
I sometimes become breathless and/or have trouble breathing
Pain interferes with my day to day life
I am concerned with my oral hygiene, teeth, or dentures
I am concerned with my skin (easily torn and/or irritated)
Allergies impact my day to day life
I have difficulty walking and/or standing up
I have a podiatrist attend to my feet
Other
Looking and feeling my best - tick all that apply to you
I have difficulty with my personal grooming (shaving, doing my make up, doing my hair)
I limit or change things that I do because I'm concerned about finding a toilet
I have difficulty showering or bathing, and need someone to help me
Other
Staying fit and healthy - tick all that apply to you
I think I need some support to improve my diet and nutrition
I find it difficult to prepare meals these days
I want to improve my physical fitness and/or strength
I'm concerned about future health issues
I want to learn new ways to reduce the effects of aging
Other
My mental and social wellbeing - tick all that apply to you
I frequently feel lonely, anxious, and/or sad
I want to look after and improve my mental wellbeing
If I had more support I would participate in more social and/or community activites
Other
Supporting my carer and/or family - tick all that apply to you
I'm worried about the amount of time that other people are spending on helping me out
I would like my carer/spouse/family to have more spare time
Other
My home and garden - tick all that apply to you
I find cleaning and/or home organisation difficult
I am unable to maintain my garden/outdoor area as well as I would like to
I can't look after my pet as well as I'd like
I am worried about the safety of my home and/or neighbourhood
I think I could manage better if I had aids and/or equipment at home (i.e. railings)
Other
Managing my day to day errands - tick all that apply to you
I need assistance with paperwork and/or personal administration
I find it difficult to do shopping, banking, and/or other errands
I have trouble getting to meetings and/or appointments
Other
Please let us know anything else that we might have missed here
Submit
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