Questionnaire to determine care needs and contact information

Questionnaire

To determine care needs and contact information.
Information about the applicant
Name of the resident*

First NameLast Name
Gender*

FemaleMale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Availability
Health insurance
Insurance company / Insurance number
Travel insurance
Insurance name / Insurance no.

Details of reference persons/trusted persons/representatives
Main contact in case of emergency
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Email*
example@example.com
Availability*
Relationship to the resident*

Additional contact in case of emergency
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Email
example@example.com
Availability
Relationship to the resident

Information about the family doctor/specialist
Name of family doctor
Phone Number

Area CodePhone Number
Address of family doctor
Note
If you decide to stay with us, we kindly ask you to request a report from your family doctor about any existing illnesses, medications, and current treatment and send it to us.

Illness/infirmity
What illness or infirmity do you suffer from?

DementiaAlzheimerParkinsonOther
What care level have you been assigned?

Care level ICare level IICare level IIINot assigned

Vital signs, monitoring, and observation
What checks have been prescribed by the doctor?

Keeping a fluid or drinking chartDaily blood sugar measurementRepeated quick checksNo checks necessary or prescribed
Is special care necessary?

Treatment of pressure ulcers (decubitus)Catheter careCare of a feeding tubeNo special care required

Intensive care
What care measures must be taken?

Suctioning the airwaysBladder irrigation with indwelling catheterChanging the urinary catheterChanging a feeding tubeI do not require nursing care
Your comment:

Mobility
Do you require mobility aids?

I am independentWith a rollatorWith a wheelchairI am prone to falls
Assistive devices
Do you use any additional aids?

GlassesHearingDenturesSonstiges
Daily routine / preferences

	Details
Eating habits
Favorite dish
Bedtime
Hobbies / interests
Cultural / religious needs

Administrative details

	Details
Planned date of arrival
Room preference Studio or care room

Should be Empty: