Questionnaire to determine care needs and contact information

Questionnaire

To determine care needs and contact information.
Applicant Information
Name

First NameLast Name
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Preferred contact time
e.g. Weekdays, 9am–5pm
Health insurance
Insurance company / Insurance number
Travel insurance
Insurance name / Insurance no.

Emergency Contact
Primary Contact Detail
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
- 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?

Other
What care level have you been assigned?

Vital signs, monitoring, and observation
What checks have been prescribed by the doctor?
Is special care necessary?

Intensive care
What care measures must be taken?
Your comment:

Mobility
Do you require mobility aids?
Assistive devices
Do you use any additional aids?

Sonstiges
Daily routine / preferences

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

Administrative details

Rows	Details
Planned date of arrival
Room preference Studio or care room

Should be Empty: