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Clinic
Care
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Risk Assessment for Transport
Fill in the
Transport
Risk Assessment Form
Fields marked with * are required.
1
Personal Details
2
Journey Details
3
Pickup Location
4
Drop-Off Location
5
Consent & Support
May I know your email id? *
What is the Service User's Name? *
What is the Phone Number(s)? *
What is the Service User's Age? *
What is the Service User's Weight? *
What is the Service User's Height? *
Do they have any Mobility? *
Yes
No
Needs Assistance
Can they assist and support themselves? *
Yes
No
Needs Assistance
Can they communicate with others? *
Yes
No
Any Spinal injuries? (If yes, further assessment is required) *
Yes
No
Are they able to be moved in the seated position? *
Yes
No
Other
Any attachments (oxygen intravenous lines)? *
Yes (State in 'Other')
No
Other
Medication that we need to Administer?
Yes (Name and dosage in 'Other')
No
Other
Does the Service User have any Health Insurance? *
Yes
No
Does the Service User have a DNAR in place? (Do Not Attempt Resuscitation) *
Yes
No
If yes, provide the DNAR number and date.
What is the communication language?*
Is there any pain in moving? (If yes, what?) *
Any general Medical Conditions? (e.g., Dementia / Diabetic / Dialysis) Or recent surgeries? *
Next
1
Personal Details
2
Journey Details
3
Pickup Location
4
Drop-Off Location
5
Consent & Support
Is a wheelchair required? *
Yes
No
Will someone be traveling with the Service User? *
Yes
No
Who (Relation)?
Please select your journey type? *
Return Journey
Wait & return journey
One Way
Wait time (if wait & return)?
Date of journey? *
Time of journey? *
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Next
1
Personal Details
2
Journey Details
3
Pickup Location
4
Drop-Off Location
5
Consent & Support
Pickup Address? * (Full address please)
Type of Building (House, care home, bungalow)?
Is Parking available? *
Yes
No
Other
Are any stairs entering the property? *
Yes
No
If yes, how many stairs and are they wide or narrow?
Are there any stairs inside the property? *
Yes
No
If yes, how many stairs and are they wide or narrow?
Are there any obstacles blocking the entrance of the property?
Yes
No
Other
Are the hallways Narrow? *
Yes
No
Is there good access around the bed? *
Yes
No
Lift in property? (Can a stretcher fit?) *
Yes
No
Booking Wheelchair
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Next
1
Personal Details
2
Journey Details
3
Pickup Location
4
Drop-Off Location
5
Consent & Support
Drop-off Address? (Full address please)*
Type of building (Hospital, care home, house)? *
Is Parking available? *
Yes
No
Other
Are any stairs entering the property? *
Yes
No
If yes, how many stairs and are they wide or narrow?
Are there any stairs inside the property? *
Yes
No
If yes, how many stairs and are they wide or narrow?
Are there any obstacles blocking the entrance of the property?
Yes
No
Other
Are the hallways Narrow? *
Yes
No
Is there good access around the bed? *
Yes
No
Lift in property? (Can a stretcher fit?) *
Yes
No
Back
Next
1
Personal Details
2
Journey Details
3
Pickup Location
4
Drop-Off Location
5
Consent & Support
Are there any turns we need to be aware of? *
Will there be carers present? *
Yes
No
If there are no carers present, do you still give us consent to move the patient? *
Yes
No
Do you give us your consent to manually move the patient if required? *
Yes
No
Do you give us consent to share details provided with our Patient care Assistants? *
Yes
No
Any other information that we need to know about to make the journey safer and smoother? *
Referral Number (if any)
Where did you hear about us?
I have read and accept the
terms and conditions.
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