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Short Breaks: Pre Check-in

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Welcome
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Form Overview

This form takes approximately 8-10 minutes to complete. You can save your progress as you go.

What we'll cover:
  • Your contact details
  • Client's personal information
  • Emergency contact
  • Medical history & current health
  • Dietary needs & preferences
You'll also tell us about:
  • Food preferences
  • Eating & swallowing needs
  • Activities & interests
  • Communication & care needs
  • What makes them unique
Helpful Tips:
Be specific: The more detail you provide, the better care we can offer.
Ask for help: If you're unsure about medical details, consult the client's GP records or family.
Take your time: Your answers help us create a personalized care plan.

Welcome

Ready to get started?

Short Breaks Pre Check-in Form

This form will help us understand your needs and preferences to provide the best possible care during your short break stay.

What to expect:
  • Time needed: Approximately 8-10 minutes
  • Auto-save: Your progress is saved automatically
  • Sections covered: Personal details, medical information, dietary needs, preferences
  • Privacy: All information is encrypted and secure
Your data is protected and will only be used to provide appropriate care

Form Filler Information

Who is completing this form?

Why we ask this: We need to know who's providing the information so we can contact you if we have questions and understand the relationship to the client.
I am the client's: *

Client Personal Details

Please provide the client's personal information

Why we ask this: Basic details help us identify the client and ensure we provide age-appropriate care in the right location.

Emergency Contact

Please provide emergency contact details

Important: This person will be contacted in emergencies. Please ensure they are readily available and authorized to make decisions if needed.

Medical Information

Please provide relevant medical and health information

The more detail you provide, the better care we can offer. Please be as specific as possible.
Specific Medical Conditions

Please check any that apply and provide details:

Dietary Requirements

Please let us know about dietary needs and requirements

This helps us prepare appropriate meals and snacks
Dietary Types
Allergies & Restrictions
Additional Notes

Food Preferences

Please indicate the client's food preferences

Meat & Poultry
Chicken:
Beef:
Pork:
Lamb:
Fish & Seafood
White Fish:
Salmon:
Prawns/Shrimp:
Vegetables
Broccoli:
Carrots:
Peas:
Potatoes:
Fruits
Apples:
Bananas:
Oranges:
Berries:
Dairy & Alternatives
Milk:
Cheese:
Yogurt:
Carbohydrates
Bread:
Rice:
Pasta:

Eating & Swallowing/SALT

Information about eating, swallowing, and speech & language therapy

Activities & Preferences

Tell us about the client's interests and activity preferences

Additional Information

Any other information that would help us provide the best care

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💡 The little things that make a big difference 0/300 characters
✨ Help us see the person behind the paperwork 0/800 characters
Data Privacy & Consent
How We Use Your Data

Data Processing: Your information is used solely to provide appropriate care and support services.

Data Retention: Personal data is kept for 7 years as per NHS guidelines, then securely destroyed.

Data Sharing: Information is only shared with authorized healthcare professionals involved in your care.

Your Rights: You have the right to access, correct, or request deletion of your personal data.

Contact: For data queries, email privacy@sevensteps.org.uk or call 01234 567890

Full Privacy Policy Summary

Legal Basis: Processing under Article 6(1)(c) and Article 9(2)(h) of GDPR for healthcare provision.

Data Controllers: Seven Steps Care Services Ltd, registered in England (Company No: 12345678).

ICO Registration: Z1234567

Data Protection Officer: dpo@sevensteps.org.uk