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Dementia assessment

Dementia Assessment
Who is completing this form?

Section

Is a social worker involved in your care?
Are you seen by a community psychiatric nurse?
Do you have an anticipatory care plan in place?
Where is your preferred place of care?
What is your smoking status?
Do you have a next of kin?
Do you have a carer?

Please provide details of your carer:

Do you give permission for your carer to deal with medical conditions on your behalf?
Do you have a power of attorney in place?

We would be grateful if you could email a copy of the POA in place to hollies.medicalpatientportal@nhs.net.

Please provide details of your POA:

Confirmation *
Confirmation *