To receive your FREE, no obligation care fees report -

please complete the following questions as fully as possible.

But don't worry if you are unable to answer some of them, we will still be able to send you a report.

You can either complete this online or print off and send to us in the post.

Your Objectives

What would you like to provide for ?

.
	The cost of care in your own home?	Now
	The cost of care in a nursing or residential home?	Very soon
		In the future
.
	Please state the amount you have been quoted to provide for long term care. If you have not yet received a quotation, then leave blank and we will base the cost on the average in you area. COST PER WEEK £
.

Details of individual(s) for whom care is to be provided.

.			Care Recipient
	Title:	Name:
	Date of birth: / / 19
.
	If you are completing this form on behalf of an elderly person, please state your relationship. E.g. daughter, nephew, friend, etc.
	Do you hold an Enduring Power of Attorney ?
.

Financial details of care recipient

Brief Medical Details

.	.	.	.
	Is the Care Recipient bed-ridden ?	Yes	No
	Is the Care Recipient wheelchair bound ?	Yes	No
	Does the Care Recipient use a zimmer frame ?	Yes	No
	Has the care Recipient fallen in the past 6 months ?	Yes	No
	Does the Care Recipient suffer from poor circulation ?	Yes	No
.	.	.
	Is the care Recipient suffering from any illness ? eg. Memory loss, arthritis, diabetes, cancer, stroke, heart problems, poor circulation etc.

Activities of daily living

	Please give details of the care recipient's ability to perform the following activities of daily living.
.	.	.	.
	Guide- Major: always requires both assistive device and personal assistance. Moderate: requires assistive device and some personal assistance. Minor: requires assistive device, but no other help or supervision. Independent: no help, assistive devices or supervision required.
.	.	.	.

Details for correspondence and other contact: it may be necessary to discuss solutions with you on the telephone: