TED Alert Assessment Form

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Home/TED Alert Assessment Form

TED Alert Assessment Formadmin2023-10-27T16:29:56+00:00

ASSESSMENT FORM:

User Name: *

First

Last

Contact Tel. No. *

Email *

Medical condition: *

No Condition
Minor Condition
Major Condition

Details: *

Medication: *

No Medication
Minor Medication
Major Medication

Details:

Last Admission to Hospital: *

More than 2 years ago
More than a year ago
Less than a year ago

Details:

Any falls? *

Never
More than a year ago
Less than a year ago

Details:

Dose the user have a Carer or Care from a family member? *

No
Yes

Details:

If yes, frequency of care from Carer or Family Member:

Once a day
Twice a day
More than twice a day

Details

EXERCISE: How much exercise do you do a week? *

Every other day
Twice a week
Less than twice a week

What exercise activities do you do?

How often do you leave your house? *

LIFESTYLE: Do you drink alcohol? *

Never
Used to
Yes

If yes, how often (alcohol)?

Daily
Weekly
Occasionally

Details:

Do you smoke? *

Never
Used to
Yes

If yes, how ofter (smoking)?

Daily
Regularely
Occasionally

Details:

HOME HAZARDS: (Tick all the applicable) *

Carpets
Trailing Leads
Clutter
Inadequate Lighting
Slippery Floors
Stairlift
Bathroom / Wet room
Home Aids Eg. Hand Rails
None of the above

Home Hazards Details, if any:

SMOKE ALARMS: How Many? How Old? When Tested? *

CO2 ALARMS: How Many? How Old? When Tested? *

HEAT ALARMS: How Many? How Old? When Tested? *

Last time home wiring was tested? *

Type of Fuseboard? *

Modern Fuseboard - consisting A) Main Switch B) Fuses with circuit breakers C) Residual Current Device
Old Style Fuseboard - consisting A) Main Switch B) Re-Wireable fuses, No RCD (Residual Current Device)

Details:

Any Fire Extinguisher or other ? *

Fire Doors? *

Yes
No

Fire Escape Plan? *

Yes
No

Bedtime Check? *

Yes
No

Keychain on door? *

Yes
No

Does the user have a Keysafe? *

Yes
No

EYESIGHT: Does the user wear glasses? *

No
Yes

When was the last time they had an eyetest? *

Within a year
Over a year ago
More than 3 years year ago

HEARING: Does the user wear a Hearing Aid? *

No
Yes

When was the last time they had a Hearing Test? *

Whin a year
Over a year ago
More than 3 years ago

Any additional information you like to provide?

111 Sheen Lane, East Sheen
LONDON, SW14 8AE
United Kingdom
Phone: (+44) 020 8408 2000
WhatsApp: (+44) 077 4278 2000
Email: info@sheenmobility.co.uk

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Rajmane Limited T/A. Sheen Mobility of 111 Sheen Lane, London, SW14 8AE, is an appointed mobility insurance representative of Mark Bates Limited t/a Premier Care of Premier House, Londonthorpe Road, Grantham, Lincs, NG31 9SN, which is authorised and regulated by the Financial Conduct Authority. Register number: 308390.

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