Create a sample Menu of Care

User details

User's first name: *

User's last name: *

User's date of birth: *

Date the user arrived: *

Continence

How many incontinence pads does the user use in one week?

Mobility

The user self-mobilises

The user requires the assistance of one carer to mobilise

The user requires the assistance of two carers to mobilise

The user requires the assistance of two carers and a hoist to mobilise

Dressing and undressing

The user is able to dress unassisted

The user needs minor assistance to dress

The user needs full assistance with dressing

Washing

The user is able to wash unassisted

The user needs minor assistance to wash

The user needs full assistance with washing

Bathing/showering

The user is able to bathe or shower unassisted

The user needs minor assistance to bathe or shower

The user needs full assistance with bathing or showering

Eating

The user is able to eat unassisted

The user needs minor assistance to eat

The user needs full assistance with eating

The user is PEG fed

Does the user require a special diet?:

Yes

Drinking

The user is able to drink unassisted

The user needs minor assistance to drink

The user needs full assistance with drinking

Medication

The user is able to self-medicate

The user needs prompting with medication

The user needs full assistance with medication

Other special needs (please specify)	Care minutes per week	Nursing minutes per week	Other related costs per week
			£
			£
			£
			£
			£

How many minutes per day does the user require further nursing care (apart from any nursing care specified above)?

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