This Is Me

Information to help you support your loved one in hospital

For some people, changes such as moving to an unfamiliar place like hospital can be unsettling and distressing. ‘This is me’ provides information about the person at the time that the document is completed. It can help health and social care staff to build a better understanding of who the person really is, what matters to them and how to care and support them in hospital. It will go with the person as they leave hospital too. If the person needs further care and support at home or moves to residential care, this information can contribute to a one-page profile, and to the person’s life story information.

The form is simple to fill in and complements the information that nursing colleagues will be gathering.

For us to work together in caring for your loved one, please put as much information as you can in the boxes below.

This Is Me

A way to capture what is important in caring for your loved one

Please upload a photo of your relative
Using a photograph is optional, but it can be really helpful for hospital staff.
Accepted file types: jpg, png, Max. file size: 5 MB.
Full Name*
What he/she likes to be called
Preferred name
The area they live in
Carer's name or the person who knows them the best
Other people who are important to him/her
Any hobbies and interests
Even if they struggle physically to do these things do they like to talk about them?
The little things that matter every day (for example, TV programmes, reading a newspaper, coffee in the morning, having a hanky to hand at all times)
Do they become upset if these things are not in place?
Routines that are important, for example first thing in the morning and last thing at night.
What are the things that he/she must have with them or around them (eg photo of his/her grandchildren next to their bed)
Anything else he/she would like us to know about what matters to them (eg. faith, culture, favourite music)
Things that may worry or upset your loved one
Anything that may upset or cause anxiety. This could be personal worries, eg money, family concerns, or being apart from a loved one, or physical needs, eg being in pain, constipated, thirsty or hungry. What does your loved one do or how do they act when they are in pain?
What makes him/her feel better if they are anxious or upset
What makes him/her feel better if they are anxious or upset. Does your loved one like touch? Who is the best person to talk to your loved one if they are upset?
How to help him/her make decisions about their care
Does your loved one need information written down? Is there a better time of day to have discussions with me?
What helps them sleep well
How they usually move around
What matters to them about their food and drinks?
Anything else your loved one would like us to know about helping them
Does your loved one like to sing songs? Do I like to talk about my childhood?
Where they have lived
What he/she has done (eg. jobs, raising a family, travel)
Any past interests and hobbies
Special times or occasions (birthdays, anniversaries, dear memories)
Date completed
DD slash MM slash YYYY
By whom
Relationship to the person being cared for
Signed by*
In adding your name to this field, you agree that the information in this leaflet may be shared with health and care workers.

This is a pilot document based on the earlier work of the Alzheimer’s Society who developed the original ‘This is me’. This version was developed with Doncaster and Bassetlaw Hospitals NHS Foundation Trust in partnership with Helen Sanderson Associates.

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