New Client Self Assessment form

Just Breathe O2|New Client Self Assessment form

    How will information about you be used?

    We are required to collect data, personal and sensitive, about you to enable us to assess your individual needs and to provide you with appropriate services and treatment plans. Your data may be shared with third parties, including NHS and medical experts, however we disclose only the information necessary to deliver treatments and services safely.
    With the exception of changes to appointments (whereby we would contact you by telephone) we may periodically contact you to keep you informed about developments within the organisation. As a client of Just Breathe O2, we will also keep in touch with you in regards to any news relevant to the organisation. If you agree to being contacted, please tick your preferred means of communication.

    For full details of our Privacy Policy and how we collect, process and store your information, please see our website www.justbreatheo2.co.uk or ask for a copy of our Privacy Policy.

    Household

    Are you currently?
    Living with partnerLiving with familyLiving aloneLiving in supported accomodationOther (please give detail)

    If you have answered Other, please give detail here:

    Do you receive a care package?
    YesNo

    If you have answered Yes, please give detail here:

    Do you provide care to someone?
    YesNo

    If you have answered Yes, please give detail here:

    Do you receive any health or social care services?
    YesNo

    If you have answered Yes, please give detail here:

    Employment

    Are you currently
    EmployedRetiredUnable to work

    Are you currently
    Full timePart TimeNot Applicable

    Are you current in receipt of any benefits?
    YesNo

    Medical Information

    Emergency Contact

    Main Carer (if applicable)

    Current issues/problems

    Health condition(s) you are seeking support with?

    Do you have any other health conditions or concerns?

    Please list your current medication(s)

    Do you use a walking/ mobility aid?
    YesNo

    If yes, please give details:

    Do you require personal assistance?
    YesNo

    If yes, please give details:

    How will you travel to use our services?
    CarPublic TransportMobility TaxiOther

    If other, please specify:

    Consent

      - I confirm my willingness to participate in Oxygen Therapy and other therapies as appropriate at Just Breathe O2 C.I.C.
      - I will inform Centre staff of any changes to my medical condition or medications.
      - I am aware that the therapy may not be beneficial to me and that it is not possible to know in advance if I will benefit.
      - I hereby give my consent for my General Practitioner and/or other health and social care agencies to be contacted concerning my suitability for therapies and/or to obtain any necessary information that may be relevant.
      - I also consent to me being transferred by patient transfer hoist or other recognised procedures as may be required on an emergency basis, but I confirm that I am aware that the Centre’s policies require me to provide for physical or other assistance under normal circumstances.
      - I give my permission for Just Breathe O2 to keep a copy of the Assessment and other records on file.
      - I accept that if I do not follow staff instructions I do so at my own risk, Just Breathe O2 will not be held liable for any accidents that occur.
      - I understand that the Centre is not part of the NHS and is a privately managed self-help social enterprise that employs professional staff and trained volunteers and relies on users and supporters in order for it to continue its work.
      - The organisation may use my email address for information and notifications regarding the organisation’s business.

    In accordance with the Data Protection Act 1998, all personal data supplied to Just Breathe O2 will be held in the strictest confidence and will not be passed on to any third parties without your consent. Your personal data will only be used for the purposes of access to the services offered by the organisation. If you have any concerns regarding the way your personal information is stored or used by Just Breathe O2, you may contact the organisation.

    Please sign your signature in the blue area below: