The Queen Alexandra Hospital Home Boundary Road, Worthing,
West Sussex, BN11 4LJ Tel: 01903 213458 Fax: 01903 219151
Registered Charity number 1072334
APPLICATION FORM
Personal Details
Surname:_______________________________________Forename(s):_____________________________________
Address________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Postcode:_______________________________________Tel:_____________________________________________
Date of Birth:____________________________________ Married
Single
Widowed
Divorced
Religion:________________________________________National Insurance No:_____________________________
War Disability Pension:
No
Yes
% Rate_______
Ref No:____________
Pensionable Disability:_____________________________________________________________________________
Recommendation By:______________________________Tel:_____________________________________________
Contact Details (If different from above:______________________________________________________________
_______________________________________________________________________________________________
Is the applicant in receipt of:
Retirement Pension
Invalidity Benefit
Income Support
Attendance Allowance
Service Pension
Other Pension: (from employer)
Disability Living Allowance
Incapacity Benefit
Service History (If Applicable)
Regiment:_______________________________________Ship or Unit:____________________________________
Rank:___________________________________________No:___________________________________________
Date of Enlistment:_______________________________ Date of Discharge:________________________________
Occupation since Discharge:________________________ Retired:
Yes
No
PLEASE STATE BRIEFLY THE NEED FOR CONVALESCENCE OR PERMANENT RESIDENCY:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Length of stay requested:_____________________________Permanancy:
Are you prepared to come at less than 7 days notice:
Yes
Yes
No
No
DOES THE APPLICANT SUFFER FROM ANY DISABILITY WHICH REQUIRES THE USE OF SPECIAL EQUIPMENT?:
Yes
No
(If so please give details)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Is there a need for:
Wheelchair:
Yes
No
Walking Frame:
Yes
No
Walking Stick:
Yes
No
Please note that we cannot provide wheelchairs – they can
be hired at your own expense
Please give the name and address of the Applicant’s Doctor*:
Name:__________________________________________________________________________________________
Address:________________________________________________________________________________________
_______________________________________________Postcode:________________________________________
Telephone Number:_______________________________National Health Service Number:_____________________
Signature of Applicant:(or on behalf of)_______________________________________Date:____________________
*Provision of this information will be taken as consent to approach him/her if required
MEDICAL QUESTIONNAIRE – TO BE COMPLETED BY APPLICANT’S DOCTOR OR HOSPITAL DOCTOR IF APPROPRIATE
Diagnosis:
_____________________________________________________________________________________________
Nature and Date of Operation/Hospitalisation (if relevant):
_______________________________________________________________________________________________
Present Clinical Condition:
_______________________________________________________________________________________________
Date of Last Medical Examination by You:
_______________________________________________________________________________________________
Medication: (Short stay Patients must bring adequate medication to cover their stay or a prescription for their required medication)
______________________________________________________________________________________________________________________
HAS THE APPLICANT SUFFERED FROM (Tick as Appropriate):
History of Angina:
Respiratory Conditions:
Emphysema:
Heart Attack:
Yes
No
Bronchitis:
(If yes, give date(s))
Asthma:
Date:______________________________________
COPD:
Is Oxygen required?
Abnormal Blood Pressure: Yes
No
Confusion:
Trans Ischaemic Attacks: Yes
No
If yes, Mild:
Severe:
Epilepsy:
Yes
No
If yes, Active?:
Yes
No
Hearing Defects:
Controlled?:
Yes
No
Sight Defects:
Diabetes Mellitus:
Yes
No
If yes, controlled by:
Yes
No
Speech Defects:
Injection:
Yes
No
Tablet:
Yes
No
Incontinence:
Diet:
Yes
No
Urinary:
Bowels:
Depression:
Yes
No
If yes, Mild:
Yes
No
Contagious/Infectious Diseases:
Severe:
Yes
No
MRSA:
C Diff:
Pressure Sores:
Yes
No
Drug Allergies:
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
No
IF YES PLEASE LIST DRUGS OVERLEAF
Drug Addiction:
Yes
No
Alcoholism:
Yes
No
Active T.B:
Yes
No
PLEASE NOTE, THOSE APPLICANTS ADMITTED WHO SUFFER
FROM DIABETES WILL NEED TO BRING THEIR OWN BLOOD
GLUCOSE MONITOR.
Any Special Dietary Requirements (i.e. Coeliac etc)
Please give details below:
DOES THE APPLICANT NEED:
DOES THE APPLICANT NEED HELP WITH:
Night Attention:
Yes
No
Washing:
Yes
No
Toileting:
Yes
No
Bathing:
Yes
No
Physiotherapy:
Yes
No
Dressing & Undressing: Yes
No
Occupational Therapy:
Yes
No
Feeding:
No
Speech & Language Therapy:
Yes
No
Does food need to be cut up: Yes
Yes
No
IF INCONTINENCE AIDS ARE REQUIRED BY AN APPLICANT, A SUFFICIENT SUPPLY OR PRESCRIPTION SHOULD BE GIVEN.
Height:_____________________________________________Weight:______________________________________
Recommended Length of Stay:______________________________________________________________________
Detailed Medical/Clinical Information ________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Signature of Doctor:
Date:
__
Name and Address:_______________________________________________________________________________