InfoAnywhere Client Profile Client Overview Client Name: TestPerson - PDF document

� � Please Note: This view was saved in October 2018. Elements of this page may have been updated, added or removed. If client data is on this screen, it is purely fictitious in nature and was taken from our test system. Please excuse the informality and incorrectness of this incomplete and fictitious data. InfoAnywhere Client Profile Client Overview Client Name: TestPerson Palliative ­ #2650 First Contact Date: Oct 27 2018 Assessment Date: Oct 27 2018 Programs / Services Requested: Anticipatory Grief ­ Groups Anticipatory Grief ­ Indiv Bowmanville Wellness Camp Caregiver Support By Volunteer Day Respite External Referral Grief And Bereavement ­ Groups Grief And Bereavement ­ Indiv Outreach ­ After Hours Outreach ­ Business Hours Overnight Respite Resident Accompaniment Rostered ­ Test Rostered ­ Test2 Spiritual Health Transportation Visiting Accompaniment Wellington Wellness * This field must be filled out at time of referral / assessment for proper MIS reporting * Programs / Services Involved: N/A Service Notes: None Recorded Personal Information Sal: ­­­­ First Name.: TestPerson Middle Name: Last Name: Palliative Address: City: ­­­ Choose One ­­­ Postal: Do Not Send Mailings: Primary Contact Method: ­­­ Choose One ­­­ Address notes / buzzer code, etc: Closest Intersection: LHIN NUMBER: ­­­ Choose One ­­­ Telephone: Tel 2: Email:

Gender: ­­­ Choose One ­­­ Date Of Birth: 0 0 Age: Unknown Health Card: VC: MRN: Ethnicity: Unspecified Health Conditions (OHRS Stat): None Religion: Unspecified Marital Status: Primary Language: Unspecified Referral Information Special Considerations: None Recorded Situational Information Life­Limiting Diagnosis: ­­­ Choose One ­­­ Client Aware Of Diagnosis: Unknown Complexity: Unspecified Service / Privacy Agreement Last Signed: Service / Privacy Agreement Renewal: Hospice Physician Role: Unknown Prognosis at service start: Unavailable Current PPS: Unspecified Diagnosis Details & None Recorded History: Medical Allergies: None Recorded Diet Information: Available Treatment Plan: Available Options: None, Options: None, Allergy ­ Eggs, Chemotherapy, Allergy ­ Radiation, Surgery, Fish/Shellfish, Palliation, Other, Allergy ­ Dairy, Allergy ­ Nuts, Allergy ­ Mushrooms, Allergy ­ Soy, Allergy ­ Sulfites, Allergy ­ Wheat/Gluten, Diabetic, Taking Food Supplements, Kosher, Lactose Intolerant, Little Appetite, No Dairy, Swallowing Difficulty, Soft Diet, Thickened Fluids, Tube

Feeding, Vegetarian, Vegan, Other, Available Options: None, Available Aphasic, Options: None, Bedridden, Assistive Devices, Constipation, Augmented Delirium, Communication, Diarrhea, Fragile, Cane, Catheter, Hearing Impaired, Colostomy, Incontinent, Crutches, Hearing Nausea, Non Aid, Hoyer Lift, Ambulatory, Incontinence Physical Symptoms: Symptoms Management: Obesity, Paralysis, Products, Oral Physical Pain, Medication, Restlessness, Oxygen, Pain Seizure Activity, Patch, Pain Pump, Shortness of Physiotherapy, Breath, Swelling, Special Mattress, Vision Impaired, Tensor, Walker, Vomiting, Wheelchair, Other Weakness, Other (details below), (details below), Available Options: CCAC, Other Organizations Involved With This Client: VON, Physical Situation: None Recorded Feelings, Attitude and Emotional Status: None Recorded Coping Methods, Socialization: None Recorded Support Services: None Recorded Smokers/Substance Abuse: None Recorded Environmental Conditions & Information Smokers In The Home: Animals In The Home: Stairs: Unknown Unknown Unknown Living Arrangements: Available Options: Alone, Child/Children, Friend(s), Parents(s), Dwelling: Partner, Relative(s), Sibling(s), Home Spouse, Other(s), Grandparent(s), Grandchild(ren), Care Partner, Institution, Others In Household: None Recorded Notes: None Recorded Client Requests For Volunteer Preferred Gender: Faith For Spiritual Support: ­­­ Choose One ­­­ No Preference

Aboriginal Buddhist Catholic Hindu Islam Jewish Non­Religious Not Requested Other Protestant Sikh ­­­ Choose One ­­­ Afrikaans Arabic Belarusian Bengali Calabrese Cantonese Czech Dutch English Esperanto Esperanto Estonian French German Greek Gujarati Hindi Hungarian Italian Japanese Korean Preferred Language of Service: Lithuanian Mandarin Marathi Ojibwa Polish Portuguese Punjabi Pushto Romanian Russian Sinhalese Slovak Spanish Swahili Tamil Teluguge Thai Twi Ukrainian Urdu Vietnamese Zulu Cultural Background: ­­­ Choose One ­­­ Aboriginal Aboriginal ­ Miqmak Afghanistani African Bangladesh Caribbean Chinese Chinese ­ China

Chinese ­ Hong Kong Chinese ­ Taiwan Dutch Eastern European English/Irish/Scottish/Welsh French French Canadian German Indian Iranian Iraqi Italian Japanese Korean Mexican Other Asian Pakistani Philippino Portuguese Russian Spanish Sri Lankan Thai Unknown Vietnamese Sun Mon Tue Wed Thu Fri Sat 9am­Noon Noon­3pm Available For Service: 3pm­6pm (choose all applicable) 6pm­9pm Overnight Respite Select All Select None Interests, Hobbies, Work None Recorded Experiences, Popular hobbies include: Memberships, Traits, Carpentry Guitar Making Luthier History, etc.: � Other Requirements: None Recorded Other Do Not Resuscitate (DNR): Preferred Location Of Death: Unknown DNR Number & Date: DNR Location: Plans In Case Of None Recorded Emergency: Plans At Time None Recorded Of Death: Funeral Plans: None Recorded Will Location & Details: None Recorded Advance Care Planning: None Recorded Additional Notes: None Recorded Priority Notes: