Furniture Height Request Form

Furniture Height Request Form

Patient name:

Ward/Level:

The Occupational Therapy team working with you would like to check the heights of your bed, chair and toilet at home to assist us in our assessments. Please ask your relative/carer to complete this form and return to the ward or alternatively call the number on the back to provide height measurements, thank you.

Has this booklet been completed in Centimetres or inches? (please circle)

Your seating preferences:

Measure from the top of the seat cushion to the floor (if possible get someone to sit on the seat to depress the cushion when measuring).

Please note, not all types of furniture are suitable for adaptive equipment. Therefore, please fill in all sections of the leaflet giving a full description as requested. 

Height of usual chair or settee when depressed: …………………………

Type of chair: Armchair/Sofa settee/Sofa armchair/high back/corner settee other (please circle)

Does this chair recline? YES/NO

Does this chair have arms? YES/NO

Please circle type of foot on chair/settee

Height of alternative chair or settee when depressed: …………………

Type of chair: Armchair/Sofa settee/Sofa armchair/high back/corner settee other (please circle)

Does this chair recline? YES/NO

Does this chair have arms? YES/NO

Please circle type of foot on chair/settee

DOWNSTAIRS TOILET:

Measure the height of the toilet:

Height with seat up (measure from the floor to the top of the porcelain bowl): ………………………..

Height with seat down (measure from the floor to the top of the toilet seat as if you were going to use the toilet): …………………….

Is there any existing equipment?  E.g. rails on walls or around toilet, raised seat, raised seat with arms (please circle)

Other: ……………………………….

Would there be a 10cm/4” gap either side of the toilet to fit equipment if needed? Yes/no

Does your toilet have any obstruction at the back of it? E.g. pipe work

What is the shape of toilet bowl? (please circle)-

UPSTAIRS TOILET:

Measure the height of the toilet:

Height with seat up (measure from the floor to the top of the porcelain bowl): ………………………..

Height with seat down (measure from the floor to the top of the toilet seat as if you were going to use the toilet): …………………….

Is there any existing equipment?  E.g. rails on walls or around toilet, raised seat, raised seat with arms (please circle)

Other: ……………………………….

Would there be a 10cm/4” gap either side of the toilet to fit equipment if needed? Yes/no

Does your toilet have any obstruction at the back of it? E.g. pipe work

What is the shape of toilet bowl? (please circle)-

Your Bed:

Measure from the top of the mattress down to the floor. (If possible, get someone to sit on the bed to depress the mattress when measuring)- see picture for demonstration

Height when bed depressed: ……………………………..

Type of bed: …………………………………………………………                                                  (metal frame, wooden slated frame, Divan, ottoman style, electric type with (head, and knee break) or (head, knee and height adjustable))

Size of bed (please circle): Single, double, King, Super king, other

Firm/soft/medium mattress (please circle)     

Please circle type of leg/foot or state none:

If you have an alternative bed available, please complete next page.

Alternative Bed if applicable:

Measure from the top of the mattress down to the floor. (If possible, get someone to sit on the bed to depress the mattress when measuring)- see picture for demonstration

 Height when bed depressed: ……………………………..

Type of bed: …………………………………………………………                                                  (metal frame, wooden slated frame, Divan, ottoman style, electric type with (head, and knee break) or (head, knee and height adjustable))

Size of bed (please circle): Single, double, King, Super king, other

Firm/soft/medium mattress (please circle)     

Please circle type of leg/foot or state none:

Occupational Therapists comments:

……………………………………………………………

Family / carers / friends comments:

……………………………………………………………

Contacts for Occupational Therapy

Worcestershire Royal Hospital

Level 0: 01905 760667

Level 2: 01905 760170

Aconbury West (outpatients): 01905 760683

Highfield Unit: 01905 760462

Alexandra Hospital

01527 512146

Kidderminster Hospital

01562 823424 EXT 53556

Feedback for Inpatient Therapies

Please scan the QR code or follow the link below: 

If you have been seen by a Physiotherapist or Occupational Therapist during your admission, please leave us some feedback by scanning the QR code or following the link and filling in the short survey.

https://apps.worcsacute.nhs.uk/PublicSurvey/AHPFeedback

Ward admitted to:__________________________________

Therapy team who treated you: _______________________

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience

We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you. 

Feedback

Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)

If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:

Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:

The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.  

Version 5.1