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Plowright Medical Centre NHS GP Surgery in West Norfolk

Carer identification & support questionnaire

Section

What is your address? *

Preferred way for us to contact you:

Telephone

SMS

Email

Letter

Do you look after someone?

Do you regularly provide unpaid care or support to another person? *

Yes

No

Unsure

Details of the person you look after

Full name: *

Date of birth (if known):

For example, 31 3 1980

Relationship to you: *

Telephone (if appropriate):

Address (if different):

Are they registered at Plowright Medical Centre? *

Yes

No

Unsure

Their GP practice (if known):

About your caring role

Why does the person need your support? *

Physical disability

Learning disability

Dementia

Mental health condition

Autism

Long-term illness

Frailty / older age

Substance misuse

Other

Please select all that apply.

Please specify: *

Approximately how many hours of care do you provide each week? *

Under 10

10–19

20–49

50 or more

Most or all of the time

Unsure

What support do you provide? *

Personal care

Medication support

Emotional support

Transport

Shopping / housework

Managing finances

Attending appointments

Other

Please select all that apply.

Please specify: *

How is caring affecting you?

Please select if caring is affecting you in the following situations.

Physical health *

Yes

No

Not sure

Mental wellbeing *

Yes

No

Not sure

Sleep *

Yes

No

Not sure

Work, education or training *

Yes

No

Not sure

Finances *

Yes

No

Not sure

Social or family life *

Yes

No

Not sure

Ability to attend your own appointments *

Yes

No

Not sure

Please tell us about any concerns or anything you would like the practice to know:

Information or support you may want

Would you like information or signposting about any of the following?

Local carers support services

Carer’s assessment

Benefits or financial support

Respite or replacement care

Emotional or mental health support

Support groups

Help balancing work and caring

Flexible appointment arrangements

Health checks or vaccination information

Other

Please select all that apply.

Please specify: *

Would you like a member of the practice team to contact you about your caring role? *

Yes

No

Children or young people who help with caring

Does anyone under 18 help you to provide care? *

Yes

No

Unsure

What is their name? *

What is their age? *

Relationship to the person receiving care: *

Your choices and consent: *

I agree to Plowright Medical Centre recording on my medical record that I am a carer.

I agree to the practice contacting me with information relevant to carers.

I would like the practice to refer or signpost me to a carers support service.

I agree to the practice sharing my contact details with a carers support service for this purpose. I understand that the practice will tell me which service before making a referral.

Please select each option that you agree to. Leaving an option unchecked will not affect your usual care.

Important: Important

Being recorded as a carer does not automatically give you permission to access another person’s medical information or make decisions for them. Any information sharing will follow confidentiality rules and the wishes or legal arrangements of the person you care for.

Confirmation *

I understand that I may change my contact preferences or withdraw consent for optional contact or referral by informing the practice.

Signature: *

Date:

If you are human, leave this field blank.

Plowright Swaffham
1 Jack Boddy Way
Swaffham
Norfolk
PE37 7HJ

Get directions

01760 722797

Plowright Necton
North Pickenham Road
Necton
Norfolk
PE37 8EF

Get directions

01760 441344

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