questionnaire Fill out the form below When should the care start? as soon as possible in 14 days in 30 days not clear Where should the care take place? What is support needed for?* personal hygiene Treatment care Nursing advice Mobilization Home help Nutrition Accompaniment Geschlecht weiblich männlich egal Deutschkenntnisse gut mittel (empfohlen) gering Führerschein ja nein egal Smoking habit unimportant will not be tolerated only outside the living area Information about the person in need of care How many people are cared for? 1 2 What gender is the person in need of care? masculine female How much does the person in need of care weigh approximately?* What level of care does the person in need of care have? Care level 1 Care level 2 Care level 3 Care level 4 Care level 5 no level of care How mobile is the person in need of care? fully mobile slightly disabled Rollator is required Wheelchair is required bedridden Is there dementia? no beginning / easy advanced Are there any special habits/hobbies? Do additional people live in the household of those in need of care? no a person Two people three persons Do additional people live in the household of those in need of care? no a person Two people three persons Your email address (required) Who should we contact? Woman Mister Family First name Last name Your phone number (required) Send
