Leeds Medical Form

Application form for Assisted pilgrims

For every pilgrim the hospitality, nursing & medical teams will:

Respect dignity
Maintain privacy
Respect confidentiality
Encourage independence where possible
Encourage participation where possible
Assist with personal care where necessary
Provide full care where necessary
Ensure adequate nutrition/hydration
Maintain a safe environment (mobility/infection control)
Ensure pilgrims have adequate protection against adverse weather (sun; heat; rain; hail etc)
Support pilgrims’ mobility needs using equipment available ONLY WHEN TRAINED IN ITS USE

Consent

I consent to the Pilgrimage Doctor/Nurse contacting my doctor for further information as required and for this information to be shared with members of the Medical Team who may be involved in my care. I understand this will be held in confidence and stored securely/destroyed after the Pilgrimage or returned to me at my request. I accept the terms & conditions of the Pilgrimage Organiser Tangney Tours. I am not travelling against medical advice.

Full Name(Required)

Date(Required)

Signed(Required)

PERSONAL DETAILS

Name (as it appears on passport)(Required)

Title(Required)

Name you like to be know by(Required)

Email Address(Required)

Date of Birth(Required)

Age(Required)

Religion

Address Line 1(Required)

Address Line 2

Postcode(Required)

Telephone (Home)

Telephone (Mobile)

COVID VACCINATION STATUS

(Vaccination is strongly recommended but not essential)

I confirm that I am fully vaccinated against COVID-19(Required)

Yes

Date of most recent vaccination

I am currently being treated for Long Covid

Yes

SPECIAL EQUIPMENT

IF YOU HAVE SPECIAL EQUIPMENT – CATHETERS; STOMA BAGS; OXYGEN TUBING; DRESSINGS ETC – PLEASE BRING EXTRA SUPPLIES WITH YOU. WE MAY NOT BE ABLE TO FIND EQUIVALENT EQUIPMENT IN LOURDES

GP

GP Name

Practice address

Telephone Number

MEDICAL CONDITIONS

Please tick if you have any of the following conditions:

Medical conditions

Do you use insulin

Yes

Date of heart attack

Other medical conditions

Have you had surgery in the last 12 months?

Yes

Please give details of your surgery

Have you been admitted to hospital/received hospital treatment in the last 21 months?

Yes

Please give details of your hospital treatment

Prescription details

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 25 MB, Max. files: 10.

If possible, please upload a photograph/s of your prescription details here.

Prescription List (if you're unable to upload a photograph of your prescription details)

LOURDES

Have you been to Lourdes before?

Yes

Year of your last visit?

EUROPEAN HEALTHCARD – ESSENTIAL (you will have to pay for emergency treatment if you do not have this)

If you have a current EHIC card it will still be valid until the expiry date. If there is less than 6 months before the expiry date you will need to apply for a new GHIC card.

The GHIC can be obtained from: https://www.gov.uk/global-health-insurance-card

EHIC/GHIC expiry date

1. WASHING/DRESSING

Please tick all that apply

Washing/Dressing

I do not need assistance

I need some assistance washing/showering/dressing

I am fully dependent on others to assist with washing and dressing

I have carers at home

Please tick all that apply

2. MOBILITY

Please tick all that apply

Mobility

Please tick all that apply

I walk with a stick/frame/other (please specify)

Please let us know if you require the assistance of 1 OR 2 people

Please tell us which special equipment is used for transferring

Does your manual wheelchair fold?

Yes

3. REST & SOCIALISING

Please tick all that apply

Rest & Socialising

I suffer from fatigue and tire quickly and I need to rest during the day

I like being with other people

I would like to attend all services while in Lourdes

4. NUTRITION & HYDRATION

Please tick all that apply

Nutrition & Hydration

I do not need assistance at meal times

I need help cutting up food

I need to stay in my wheelchair in the dining room

I am fully dependent on others

I have a special diet (please specify below)

I use special equipment (please bring this with you)

I have difficulty swallowing/I need thickened fluids

I have a PEG/I am Nil By Mouth

I have a special diet

Diabetic

Soft

Pureed

Gluten Free

Vegetarian

Other

5. SAFETY & COMFORT

Please tick all that apply

Safety & Comfort

I need a rise and fall (profiling/hospital) bed

I use bedrails at home

I have a monkey pole/bedstick at home

I need a special mattress - an airflow mattress can be provided

I have reduced hearing/sight/speech

I am unsteady and my balance is not good

I have had a fall in the last 6 months

I have reduced hearing/sight/speech - please add any aids

6. BLADDER/BOWELS

Please tick all that apply

Bladder/Bowels

I do not need assistance with using the toilet

I need some assistance

I need a commode close to my bed

I have a urinary catheter/suphrapubic catheter - Please bring spare supplies with you

I need help washing myself after an 'accident'

I suffer from constipation/loose stools/incontinence

I have a stoma

I need regular bowel care

I have a stoma

I manage it independently

I need assistance with my stoma

7. SKIN

Please tick all that apply

Skin

I have no skin problems

I have fragile skin and bruise easily

I have cellulitis/oedema/rash/dry skin

I need assistance applying cream

I have dressing(s) that will need to be changed whilst in Lourdes (you will need to bring dressings with you)

I need regular positional changes

I have a pressure injury

Please specify which condition(s) you have

Cellulitis

Oedema

Rash

Dry Skin

How often do you need positional changes?

Please specify the Grade of your pressure injury (if known)

8. STATE OF MIND

Please tick all that apply

State of Mind

I do not have any mental health problems

I have mental health problems

I may require support for Anxiety/Depression/Confusion/Dementia

I have recently been bereaved

I have mental health problems - please state

I may require support for

Anxiety

Depression

Confusion

Dementia

9. SLEEP

Please tick all that apply

Sleep

I am independent getting in & out of bed

I need help getting in & out of bed

I sleep well

I often wake and need company/cup of tea/pain relief

How many assistants do you need to get in & out of bed?

When I awake I need

Company

Cup of tea

Pain relief

10. PAIN

Please tick all that apply

Pain

I do not have any pain

I have pain that is controlled by medication

My pain is not well controlled

I have a syringe driver

11. MEDICATIONS

Please tick all that apply

Medications

I manage my own medications

I need to be reminded to take medication

I need a nurse to administer my medication

I use an inhaler/I use a nebulizer

I have regular injections

You have regular injections (Please state what type of medication)

12. BREATHING

Please tick all that apply

Breathing

I get short of breath

I use oxygen

I have sleep apnoea

Do you get short of breath...

At rest

On exertion

Do you oxygen...

Occasionally

All the time

Do you use CPAP at night?

Yes

ALLERGIES

I am allergic to

What happens if you take the above?

I have an Epipen

Yes

Please make sure you have it with you at all times

NEXT OF KIN (IN UK)

Name(Required)

Telephone Number(Required)

Relationship(Required)

TO BE COMPLETED BY THE LOURDES PILGRIMAGE NURSE

Form Received

Signed

Name

Date Contact Made

Falls risk

Low

Medium

High