{ "Local-Mind-Triage-Request.pdf": { "form": "./forms/Local-Mind-Triage-Request.pdf", "fields": [ { "description": "Full Name", "top_left_x": 137, "top_left_y": 685, "bottom_right_x": 327, "bottom_right_y": 653, "text": "", "format": "words", "page": 0 }, { "description": "Date of birth", "top_left_x": 152, "top_left_y": 635, "bottom_right_x": 336, "bottom_right_y": 606, "text": "", "format": "DD/MM/YYYY", "page": 0 }, { "description": "Email Address", "top_left_x": 161, "top_left_y": 561, "bottom_right_x": 337, "bottom_right_y": 521, "text": "", "format": "email", "page": 0 }, { "description": "Address", "top_left_x": 122, "top_left_y": 482, "bottom_right_x": 335, "bottom_right_y": 437, "text": "", "format": "address, sans postcode", "page": 0 }, { "description": "Postcode", "top_left_x": 131, "top_left_y": 438, "bottom_right_x": 294, "bottom_right_y": 394, "text": "", "format": "Uk postcode format", "page": 0 } ] }, "Primary-Health-Support-Referral.pdf": { "form": "./forms/Primary-Health-Support-Referral.pdf", "fields": [ { "description": "NHS Number", "top_left_x": 238, "top_left_y": 651, "bottom_right_x": 500, "bottom_right_y": 625, "text": "", "format": "UK NHS number format", "page": 0 }, { "description": "Area of need", "text": "", "format": "Select from the following options", "page": 0, "choices": [ { "text": "counselling/ therapy", "top_left_x": 265, "top_left_y": 568, "bottom_right_x": 284, "bottom_right_y": 551 }, { "text": "peer support group", "top_left_x": 266, "top_left_y": 531, "bottom_right_x": 282, "bottom_right_y": 515 }, { "text": "financial support", "top_left_x": 261, "top_left_y": 487, "bottom_right_x": 286, "bottom_right_y": 469 }, { "text": "general support", "top_left_x": 266, "top_left_y": 444, "bottom_right_x": 282, "bottom_right_y": 427 } ] }, { "description": "Has a current GP referral", "top_left_x": 238, "top_left_y": 345, "bottom_right_x": 359, "bottom_right_y": 323, "text": "", "format": "Yes or No", "page": 0 }, { "description": "Also applying for NHS low-income scheme?", "top_left_x": 239, "top_left_y": 234, "bottom_right_x": 360, "bottom_right_y": 211, "text": "", "format": "Yes or No", "page": 0 }, { "description": "Preferred language for service?", "top_left_x": 240, "top_left_y": 171, "bottom_right_x": 509, "bottom_right_y": 146, "text": "", "format": "word or words", "page": 0 } ] }, "Health-Cost-Exemption.pdf": { "form": "./forms/Health-Cost-Exemption.pdf", "fields": [ { "description": "First Name", "top_left_x": 103, "top_left_y": 663, "bottom_right_x": 289, "bottom_right_y": 639, "text": "", "format": "word", "page": 0 }, { "description": "Last Name", "top_left_x": 306, "top_left_y": 663, "bottom_right_x": 492, "bottom_right_y": 638, "text": "", "format": "word", "page": 0 }, { "description": "Contact Number", "top_left_x": 101, "top_left_y": 586, "bottom_right_x": 287, "bottom_right_y": 565, "text": "", "format": "UK Phone number format", "page": 0 }, { "description": "Email Address", "top_left_x": 306, "top_left_y": 586, "bottom_right_x": 493, "bottom_right_y": 563, "text": "", "format": "email", "page": 0 }, { "description": "Address Street", "top_left_x": 102, "top_left_y": 510, "bottom_right_x": 494, "bottom_right_y": 487, "text": "", "format": "First line of address, including house number", "page": 0 }, { "description": "Address Line 2", "top_left_x": 102, "top_left_y": 456, "bottom_right_x": 493, "bottom_right_y": 433, "text": "", "format": "Second line of address", "page": 0 }, { "description": "Town or City", "top_left_x": 102, "top_left_y": 402, "bottom_right_x": 291, "bottom_right_y": 379, "text": "", "format": "word or words", "page": 0 }, { "description": "Country", "top_left_x": 306, "top_left_y": 404, "bottom_right_x": 494, "bottom_right_y": 379, "text": "", "format": "only Wales or United Kingdom", "page": 0 }, { "description": "Postcode", "top_left_x": 102, "top_left_y": 347, "bottom_right_x": 492, "bottom_right_y": 324, "text": "", "format": "UK postcode format", "page": 0 }, { "description": "Annual Household Income", "top_left_x": 94, "top_left_y": 741, "bottom_right_x": 286, "bottom_right_y": 719, "text": "", "format": "Number", "page": 1 }, { "description": "Do you have savings or investments over £16000", "text": "", "format": "Select from the following options", "page": 1, "choices": [ { "text": "Yes", "top_left_x": 99, "top_left_y": 679, "bottom_right_x": 113, "bottom_right_y": 672 }, { "text": "No", "top_left_x": 99, "top_left_y": 659, "bottom_right_x": 110, "bottom_right_y": 652 } ] }, { "description": "Occupation Status", "text": "", "format": "Select from the following options", "page": 1, "choices": [ { "text": "Employed", "top_left_x": 99, "top_left_y": 606, "bottom_right_x": 113, "bottom_right_y": 597 }, { "text": "Unemployed", "top_left_x": 99, "top_left_y": 586, "bottom_right_x": 110, "bottom_right_y": 578 }, { "text": "Retired", "top_left_x": 99, "top_left_y": 569, "bottom_right_x": 110, "bottom_right_y": 558 }, { "text": "Student", "top_left_x": 99, "top_left_y": 548, "bottom_right_x": 110, "bottom_right_y": 542 }, { "text": "Carer", "top_left_x": 99, "top_left_y": 531, "bottom_right_x": 110, "bottom_right_y": 523 } ] }, { "description": "Chronic condition you experience", "text": "", "format": "Select from the following options", "page": 2, "choices": [ { "text": "Diabetes", "top_left_x": 99, "top_left_y": 738, "bottom_right_x": 113, "bottom_right_y": 729 }, { "text": "Epilepsy", "top_left_x": 99, "top_left_y": 718, "bottom_right_x": 113, "bottom_right_y": 708 }, { "text": "Arthritis", "top_left_x": 99, "top_left_y": 701, "bottom_right_x": 113, "bottom_right_y": 692 }, { "text": "Other", "top_left_x": 99, "top_left_y": 680, "bottom_right_x": 112, "bottom_right_y": 673 } ] }, { "description": "Prescribed medications", "top_left_x": 99, "top_left_y": 630, "bottom_right_x": 494, "bottom_right_y": 374, "text": "", "format": "Comma separated list", "page": 2 }, { "description": "Declaration as an ordinary resident in Wales", "text": "Yes", "format": "Only Yes. Text is filled in, do not ask.", "page": 2, "choices": [ { "text": "Yes", "top_left_x": 101, "top_left_y": 329, "bottom_right_x": 112, "bottom_right_y": 321 } ] } ] }, "Specialised-Mobility-Aid-Request.pdf": { "form": "./forms/Specialised-Mobility-Aid-Request.pdf", "fields": [ { "description": "Full Name", "top_left_x": 73, "top_left_y": 658, "bottom_right_x": 258, "bottom_right_y": 631, "text": "", "format": "words", "page": 0 }, { "description": "Is a supporting physiotherapist or occupational therapist willing to sign off on this request?", "text": "", "format": "Select from the following options", "page": 0, "choices": [ { "text": "yes", "top_left_x": 67, "top_left_y": 186, "bottom_right_x": 91, "bottom_right_y": 163 }, { "text": "no", "top_left_x": 152, "top_left_y": 180, "bottom_right_x": 175, "bottom_right_y": 167 } ] }, { "description": "Date of birth", "top_left_x": 73, "top_left_y": 607, "bottom_right_x": 212, "bottom_right_y": 583, "text": "", "format": "UK date format", "page": 0 }, { "description": "NHS Number", "top_left_x": 73, "top_left_y": 558, "bottom_right_x": 277, "bottom_right_y": 530, "text": "", "format": "UK NHS number format", "page": 0 }, { "description": "Current mobility aids in use", "top_left_x": 72, "top_left_y": 432, "bottom_right_x": 444, "bottom_right_y": 382, "text": "", "format": "Comma separated list", "page": 0 }, { "description": "Specialised mobility aids requested", "top_left_x": 70, "top_left_y": 356, "bottom_right_x": 414, "bottom_right_y": 300, "text": "", "format": "Comma separated list", "page": 0 }, { "description": "Daily mobility score", "top_left_x": 70, "top_left_y": 253, "bottom_right_x": 202, "bottom_right_y": 226, "text": "", "format": "Numerical score of 1 to 10. 1 Indicating immobility, 10 indicating high independence. If a mobility score is not directly mentioned, try to infer a score. If a score cannot be confidently inferred, then ask follow up questions.", "page": 0 } ] }, "CHC-Initial-Screening.pdf": { "form": "./forms/CHC-Initial-Screening.pdf", "fields": [ { "description": "Surname", "top_left_x": 93, "top_left_y": 445, "bottom_right_x": 420, "bottom_right_y": 420, "text": "", "format": "word", "page": 0 }, { "description": "All other names, sans surname", "top_left_x": 93, "top_left_y": 356, "bottom_right_x": 420, "bottom_right_y": 335, "text": "", "format": "word", "page": 0 }, { "description": "Residential status", "text": "", "format": "Select from the following options", "page": 0, "choices": [ { "text": "own home", "top_left_x": 99, "top_left_y": 235, "bottom_right_x": 119, "bottom_right_y": 226 }, { "text": "residential care", "top_left_x": 101, "top_left_y": 211, "bottom_right_x": 115, "bottom_right_y": 205 }, { "text": "hospital ward", "top_left_x": 98, "top_left_y": 190, "bottom_right_x": 117, "bottom_right_y": 180 } ] }, { "description": "Mobility support need score", "text": "", "format": "Select a number from 1 to 6. 1 being totally independent and 6 being totally dependent.", "page": 1, "choices": [ { "text": "1", "top_left_x": 125, "top_left_y": 465, "bottom_right_x": 135, "bottom_right_y": 460 }, { "text": "2", "top_left_x": 150, "top_left_y": 465, "bottom_right_x": 160, "bottom_right_y": 460 }, { "text": "3", "top_left_x": 175, "top_left_y": 465, "bottom_right_x": 185, "bottom_right_y": 460 }, { "text": "4", "top_left_x": 200, "top_left_y": 465, "bottom_right_x": 210, "bottom_right_y": 460 }, { "text": "5", "top_left_x": 225, "top_left_y": 465, "bottom_right_x": 235, "bottom_right_y": 460 }, { "text": "6", "top_left_x": 250, "top_left_y": 465, "bottom_right_x": 260, "bottom_right_y": 460 } ] }, { "description": "Communication support need score", "text": "", "format": "Select a number from 1 to 6. 1 being totally independent and 6 being totally dependent.", "page": 1, "choices": [ { "text": "1", "top_left_x": 125, "top_left_y": 300, "bottom_right_x": 135, "bottom_right_y": 295 }, { "text": "2", "top_left_x": 150, "top_left_y": 300, "bottom_right_x": 160, "bottom_right_y": 295 }, { "text": "3", "top_left_x": 175, "top_left_y": 300, "bottom_right_x": 185, "bottom_right_y": 295 }, { "text": "4", "top_left_x": 200, "top_left_y": 300, "bottom_right_x": 210, "bottom_right_y": 295 }, { "text": "5", "top_left_x": 225, "top_left_y": 300, "bottom_right_x": 235, "bottom_right_y": 295 }, { "text": "6", "top_left_x": 250, "top_left_y": 300, "bottom_right_x": 260, "bottom_right_y": 295 } ] }, { "description": "Psychological support need score", "text": "", "format": "Select a number from 1 to 6. 1 being totally independent and 6 being totally dependent.", "page": 1, "choices": [ { "text": "1", "top_left_x": 125, "top_left_y": 135, "bottom_right_x": 135, "bottom_right_y": 130 }, { "text": "2", "top_left_x": 150, "top_left_y": 135, "bottom_right_x": 160, "bottom_right_y": 130 }, { "text": "3", "top_left_x": 175, "top_left_y": 135, "bottom_right_x": 185, "bottom_right_y": 130 }, { "text": "4", "top_left_x": 200, "top_left_y": 135, "bottom_right_x": 210, "bottom_right_y": 130 }, { "text": "5", "top_left_x": 225, "top_left_y": 135, "bottom_right_x": 235, "bottom_right_y": 130 }, { "text": "6", "top_left_x": 250, "top_left_y": 135, "bottom_right_x": 260, "bottom_right_y": 130 } ] }, { "description": "Continence frequency of support required", "top_left_x": 91, "top_left_y": 541, "bottom_right_x": 421, "bottom_right_y": 513, "text": "", "format": "Free text to explain level of required support.", "page": 2 }, { "description": "I confirm that this reflects the last 7 days of care needs", "text": "", "format": "Only yes. If any other answer is inferred, then the applicant is not eligible for this form.", "page": 2, "choices": [ { "text": "yes", "top_left_x": 98, "top_left_y": 421, "bottom_right_x": 110, "bottom_right_y": 412 } ] } ] } }