kancare

Enquiry Details

Date of call

Name of the caller

Name of client

Contact Number of caller

Age

Sex

Relationship to client

Current location of the client

DETAILS OF DIAGNOSIS AND CO-MORBIDITIES (Select all applicable)

Stroke	Age-related	Surgery and Rehab
Alzheimers / Dementia	Accident	Liver failure / Cirrhosis
Cancer	Fall / Fracture	Brain injury / Bleed
Hypertension	Diabetes Mellitus	Others

Details of the disease: (Additional information, if any)

GENERAL CONDITION OF THE PATIENT (Choose the options applicable)

Activity	Options
Bedbound	Yes No
Mobility / Walking	Self Assisted Dependent
Dressing	Self Assisted Dependent
Toiletry	Self Assisted Dependent
Diaper use	Yes No
Catheter use	Yes No Date of catheterizatio
Feeds 1	Self Assisted
Feeds 2	Veg Non veg
Feeds 3	RT Feeds PEG Feeds
Tracheostomy	Yes No
Oxygen support	Yes No
Violent behaviour(aggression)	Yes No
Wandering	Yes No

RECENT HOSPITALISATION DETAILS

Name of the hospital

Name of treating doctor

Date of admission

Date of discharge

ADMISSION: ROOM ALLOCATION DETAILS

Expected date of admission

Type of stay
Long stay Short stay
For short stay(Specify duration):

Source of funding: (eg: pension, others… to give details)

Family details:

No: of children

No: of children abroad

Anyone in Ernakulam

Details of local contact

Source of reference:

Offline Sources

Doctor referral

Patient referral

Staff referral

Online Sources

Google

Social media

Others

Particulars

SCHEDULING CENTRE VISIT

Date and time

Name of person visiting

Contact number

Remarks

INFORMATION SENT TO CLIENT FAMILY

Video Pricing details Kancare Promo message

HOME ASSESSMENT FOR LOCAL CONTACTS

To be conducted:
Yes No

If yes, Scheduled Date & Time

Call start time

Call end time

Call duration(minutes)

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