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Den Fragebogen als PDF (zum downloaden) gibt es hier: PDF-Datei

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Fragebogen

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Angaben zur pflegebedürftigen Person:

Name Name der pflegebedürftigen Person.
Vorname Vorame der pflegebedürftigen Person.
Anschrift Anschrift der pflegebedürftigen Person.
Geburtsdatum Geburtsdatum der pflegebedürftigen Person.
Telefonnummer Telefonnummer der pflegebedürftigen Person.
Gewicht (in kg) Gewicht der pflegebedürftigen Person.
Größe (in cm) Größe der pflegebedürftigen Person.
Alter Alter der pflegebedürftigen Person.

Pflegebedürftigkeit:

Pflegestufe:
Diagnose:
Mobilität, falls eingeschränkt:
Bettlägerig
Inkontinenz
Einschränkungen beim:
Sonstiges (bitte auflisten)
Informationen zum Haushalt
Ein separates Zimmer für das Personal ist vorhanden:
Haustiere

Angaben zu den Kontaktpersonen / Angehörigen:

1. Person

Name
Vorname
Geburtsdatum
Anschrift
Telefonnummer
Handy
Email
Verwandtschaftsgrad zur pflegebedürftigen Person

2. Person

Name
Vorname
Geburtsdatum
Anschrift
Telefonnummer
Handy
Email
Verwandtschaftsgrad zur pflegebedürftigen Person

Anforderung an die betreuende Person:

Gewünschter Arbeitsbeginn Wunschdatum auswählen.
Wenn kurzfristige Einsatzdauer geplant ist, bis wann?
Geschlecht
Alter
Gewünschte Deutschkentnisse:
Nichtraucher
Führerschein
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