My Health Action Plan My Health Action Plan Private so you must ask me before you look at it A Health Action Plan booklet for people with a learning disability who live in Worcestershire My picture
Emergency Contact Numbers Carer/Family Name: Number: GP Name: Number: Name: Number: Name: Number: Name: Number: Name: Number: Name: Number: 2
Year: Action Points This is a list of things that I will try to do, before my next health check, for example: exercise regularly eat healthily socialise with my family and friends My list of things to do: 1. 2. 3. 4. 3
Year: Action Points This is a list of things that I will try to do, before my next health check, for example: exercise regularly eat healthily socialise with my family and friends My list of things to do: 1. 2. 3. 4. 4
About Me My name is: My date of birth is: I live at: My telephone number is: I am: White/british Mixed race Asian or Asian British Black or Black British Other Ethnic Group: My nationality is: Language spoken: I need a translator: My religion is: 5
About Me I am allergic to: This is how I show when I am in pain: This is how I show when I am ill: I have some health needs: My diagnosis is: My health needs are: Other things you need to know: This person helps me with my health needs: Name: Address: Telephone number: 6
About Me I am able to make my own decisions about my health: I need help to make decisions about my health: I like to be involved in making decisions about my health: I have a communication plan: How you can help me make decisions: I would like these people to be involved in making decisions about my health: Name: Address: Telephone number: 7
Please tell us about your parents health Some health issues run in families Mum Dad Weight Epilepsy Diabetes Blood pressure Heart problems Cataracts 8
Health Action Plan Sections My Health Action Plan Health Need Plan Date of Health Review Completed? Yes or No Area of Need Health Healthy eating and weight Click here to enter Yes No Click here to enter Breathing and circulation Click here to enter Yes No Click here to enter Hearing Click here to enter Yes No Click here to enter Eyesight Click here to enter Yes No Click here to enter Teeth Click here to enter Yes No Click here to enter Feet Click here to enter Yes No Click here to enter 9
Health Action Plan Sections My Health Action Plan Health Need Plan Date of Health Review Completed? Area of Need Health Skin Skin Click here to enter Yes No Click here to enter Continence Click here to enter Yes No Click here to enter Sleep Click here to enter Yes No Click here to enter Mobility Click here to enter Yes No Click here to enter Mental Health Click here to enter Yes No Click here to enter Drugs and Alcohol Click here to enter Yes No Click here to enter 10
Health Action Plan Sections My Health Action Plan Health Need Plan Date of Health Review Completed? Yes or No Area of Need Health Medication Click here to enter Yes No Click here to enter Women s Health Click here to enter Yes No Click here to enter Epilepsy Click here to enter Yes No Click here to enter Diabetes Click here to enter Yes No Click here to enter 11
About my healthy eating and weight I have to keep to a diet: Details of my diet: I have eating, drinking and/ or swallowing difficulties: My food and drink is taken: By mouth Via PEG A mix of both I have medication to help with saliva control (drooling): The person who helps with my eating and drinking is: Speech and Language Therapist Name: Telephone number: Dietician Name: Telephone number: Homeward Nurse Name: Telephone number: 12
There is a plan to help me with this: This person helps me with healthy eating: Name: Address: Telephone number: How people can help me with my diet: How people can help me when I go to health appointments: 13
Weight Date Weight Gain or Loss 14
My healthy eating action plan Action Plan 15
About my heart, breathing and circulation I have a healthy heart: I have normal blood pressure: I have good circulation: I breathe normally: I exercise regularly: 16
I have asthma: I carry an inhaler with me: I have asthma attacks: every day every week every month not very often My asthma attacks last for: How people can help me when I have an asthma attack: Other information, for example, specific triggers and hayfever: How people can help me when I go to health appointments: 17
My breathing and circulation action plan Action Plan 18
About my hearing I can hear well: An audiologist is a person who checks your hearing. Name: Address: Telephone number: I cannot hear very well in: Left ear Right ear Details of my hearing aids: I need: a hearing test every: a check up for ear wax every: to see my audiologist every: to check the batteries in my hearing aid: 19
How people can help me when I go to health appointments: My hearing action plan Action Plan 20
About my eyesight I can see well: An optician is a person who checks your eyesight. Name: Address: Telephone number: I can t see very well in my: Left eye Right eye I can t see at all in my: Left eye Right eye I wear glasses: Sometimes I wear contact lenses: Sometimes 21
I need an eyesight test every: Other information, for example, cataract, tunnel vision: How people can help me when I go to health appointments: My eyesight action plan Action Plan 22
About my teeth How often do you go to the dentist? A dentist is a person who checks your teeth. Name: Address: Telephone number: My teeth are OK: I have problems with my teeth: Details: I need to see the dentist every: I need to clean my teeth every: 23
Other information, for example, dentures, braces: Click here to enter How people can help me when I go to health appointments: My dental health action plan Action Plan 24
About my feet I have healthy feet: A podiatrist is a person who checks if you have healthy feet. Name: Address: Telephone number: I need to see my podiatrist every: I need specialist footwear or orthotics: How people can help me when I go to health appointments: 25
My foot health action plan Action Plan 26
About my skin Skin I have good skin: Skin I have pressure sores: Level 1 2 3 4 Date I first had pressure sores: Date pressure sores healed: Skin A skin specialist is a person who checks if you have good skin. Name: Address: Telephone number: I need to see a skin specialist every: I look after my skin by: Other information, for example, acne, sensitive to sun and other conditions: 27
How people can help me when I go to health appointments: My skin health action plan Action Plan 28
About my continence This means being able to control when I wee or poo. I can use the toilet by myself: This is the person who helps me with continence: Name: Address: Telephone number: I wear a pad during the day: I wear a pad at night: I get a lot of urinary tract infections (pain when I wee): I need to go to the toilet a lot: I need some help with going to the toilet: 29
Other information, for example, incontinence, prone to constipation: How people can help me when I go to health appointments: My continence action plan Action Plan 30
About my sleep I sleep well: Sometimes When I don t sleep it is because of: I normally go to bed at: I normally wake up at: How people can help me if I am tired during the day: Click here to enter I have a medical condition that affects my sleep: Click here to enter 31
I have a 24 hour positioning programme and/or sleep system: This is reviewed by: How people can help me when I go to health appointments: My sleep action plan Action Plan 32
About my mobility I have good mobility: I am in pain when I move: I have uncontrolled movements such as muscle spasms: I have loss of movement: I have permanent physical disabilities: I use mobility equipment: I use equipment aids: 33
I use equipment to help me get comfortable or be moved, e.g. a hoist, a wheelchair : These are: Supplied by: This is the person I see about my mobility problems : Name: Address: Telephone number: How people can help me when I go to health appointments: 34
My mobility action plan Action Plan 35
About my mental health I have good mental health: I have been mentally unwell in the past: This person helps me with my mental health: Name: Address: Telephone number: Sometimes I hurt myself: Sometimes I hurt other people: I have a Wellness Recovery Action Plan: 36
I need: a review of my medication every: a meeting to look at my care every: an appointment at the hospital every: How people can help me when I go to health appointments: 37
My mental health action plan Action Plan 38
Cigarettes, vaping, alcohol and drugs I smoke cigarettes or a personal vaper: How many cigarettes or personal vapers each day? I drink alcohol: Sometimes I like to drink with friends: I drink alone:? I have alcohol: once a week: 2-3 times a week: every day: I use drugs that have not been prescribed by a doctor, or bought at a chemist: Details: 39
How people can help me when I go to health appointments: Cigarettes or vaping, alcohol, drug use action plan Action Plan 40
About my immunisations I have had the following injections: Yes No Date Tetanus Mumps, measles, rubella Meningitis Hepatitis Polio/diptheria Flu Tuberculosis Whooping cough 41
I take medicine or tablets every day: This person helps me take my medication: Name: Address: Telephone number: This person helps me to re-order my medication: Name: Address: Telephone number: Is there anything I must not eat or drink when I am taking medication: I have to ask my doctor or the chemist before taking other tablets: I have difficulty taking medications: I need my medications in: Liquid Powder Small tablet Large Tablet Capsule Other 42
The doctor has said that I can take my medicines in/with food as I do not have capacity to consent : How people can help me when I go to health appointments: 43
About my medication I need: a review of my medication, with a doctor, every: a blood test to check the levels of my medication, every: Name of medication Regular or as and when required What it is for What kind of medication it is (eg. tablet, liquid) and how I take it How much I take What time I take it Side effects 44
Name of medication Regular or as and when required What it is for What kind of medication it is (eg. tablet, liquid) and how I take it How much I take What time I take it Side effects 45
My medication and immunisations action plan Action Plan 46
About my women s health I have good sexual health: Don t know This is the person I see about my sexual health: Name: Address: Telephone number: My periods: are regular: are irregular: have finished (menopause): I have regular personal health checks: Smear test: Breast examination (mammogram) Bowel cancer check (for 60+) 47
I have contraception advice: I need: a smear test every: breast screening every: to examine my own breasts and report if there are any changes. or my carers to note any changes to my body and help me to see my doctor. to review contraception every: Other information: How people can help me when I go to health appointments: 48
My women s health action plan Action Plan 49
About my epilepsy I have epilepsy or fits: This is the person who needs to be notified after I have a seizure: Name: Address: Telephone number: The type of seizures I have are: seizure type 1: seizure type 2: seizure type 3: I have an epilepsy plan which describes my seizures and how to manage them: Where it is kept: 50
Seizures usually happen: daily: weekly: monthly: rarely: Things that trigger my seizures are: My seizure usually lasts for: When I am having a seizure I usually: How people can help me when I am having a seizure: How people can help me after I have a seizure: I take regular medication for my seizures: I have emergency medication for my seizures: Where it is kept: 51
How people can help me when I go to health appointments: My epilepsy health action plan Action Plan 52
About my diabetes I have diabetes:? Type 1 Type 2 I have had diabetes for years and months. I have to keep to a diet: My diet needs to be: This person helps me with my diet: Name: Address: Telephone number: 53
I use tablets to control my diabetes: I use insulin to control my diabetes: I can inject insulin myself: I use an insulin pump: This person helps me with my injections or my pump: Name: Address: Telephone number: How often I need to check my blood sugar levels: What I need to do if my blood sugar level is too high or too low: 54
I need to: follow a diet: See about this in the healthy eating and weight section have a regular eye check at the opticians and retinopathy: See about this in my eyesight section receive regular foot care from the podiatrist: See about this in my feet section attend 6 monthly appointments at diabetic clinic: See about this in my diabetes section How people can help me when I go to health appointments: 55
My diabetes health action plan Action Plan 56
My useful telephone numbers Name Who they are Telephone number 57
Useful telephone numbers Community Learning Disability Teams: Wyre Forest: 01905 846 846 Bromsgrove and Redditch: 01905 846 888 Wychavon and Malvern: 01905 845 439 Worcester and Droitwich: 01905 844 716 GP Link Nurse: Hospital Link Nurses: Kay Dalloway: 07918 748 469 Jane Bullock: 07767 442 222 Emergency Dental Department: Worcester: 01905 681 796 Kidderminster: 01562 514 515 GP, out of hours: 0300 1233211 NHS 111 Service: 111 Samaritans: 01905 763 333 Alexandra Hospital: 01527 503 030 Kidderminster Hospital: 01562 823 424 Worcestershire Royal Hospital: 01905 763 333 58