Liparus offers 24-hour care in your home
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+385 97 626 2733
Mon-Fri:
09:00 – 17:00
available 24 hours a day in an emergency
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Nursing homes in Croatia
Questionnaire
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Questionnaire
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Contact
Contact details
Name of the contact person
Date of birth
Street and number
City and country
Telephone / Mobile phone
Email
Relationship between the patient and the contact person
Name of the patient/
Date of birth
Street and number
City and country
Telephone / Mobile phone
Height
Weight
Does the patient live alone?
yes
no
The patient lives with:
Degree of care
No
1
2
3
4
5
Needed
No
1
2
3
4
5
Care service
Do you receive care service at home currently?
yes
no
Should the service of carers still be used?
yes
no
What kind of care needs to be done?
Diagnoses / Limitations
Diagnosen
Age-related mobility issues
Hypertension
Alzheimer
Asthma
Heart attack
Parkinson
Diabetes
Osteoporosis
Depression
Decubitus
Rheumatism
Multiple sclerosis
Cardiac arrhythmia
Tracheostomy
Chronic diarrhea
Cardiac insufficiency
Incontinence
Incipient dementia
Dementia
Dementia
Diagnoses
Night disorders / sleep disorders
Tendency to escape
Disorientation in your own home
Aggressive / defensive behavior
Disorientation outside one's own home
Demenz bezeichnung
Tumor / cancer diseases
Tumor / cancer diseases
Tumor / cancer diseases - description
Stroke, disabilities
Stroke, disabilities
Stroke, disabilities - description
Other
Other
Other - description
Allergies
Allergies
Allergies - description
Communication
Talking
good
temporary
not possible at all
Hearing
good
temporary
not at all
Vision
good
temporary
not at all
Aiding device
Hearing device
yes
no
Glasses
yes
no
Orientation
Temporal
good
temporary
not at all
Local orientation
good
temporary
not at all
Recognizing people
good
temporary
not at all
Mobility
good on foot
walks with the help of rollator
immobile
walks with a stick
mobile only with a wheelchair
Additional information
Transfer bed / wheelchair
independent
supportive
completely in need of help
Stationary aiding devices
Medical bed
Lifter
Decubitus mattress
Climbing stairs
independent
with support
unable
Other aiding devices?
Personal hygiene
Face
independent
partly independent
with instructions
complete support
Oral Care / Dentures
independent
partly independent
with instructions
complete support
Upper body
independent
partly independent
with instructions
complete support
Buttocks / legs
independent
partly independent
with instructions
complete support
Intimate hygiene
independent
partly independent
with instructions
complete support
Combing and washing hair
independent
partly independent
with instructions
complete support
Shaving
independent
partly independent
with instructions
complete support
Hand care
independent
partly independent
with instructions
complete support
Foot care
independent
partly independent
with instructions
complete support
Bathing / showering
independent
completely in need of help
daily
supportive
weekly
Urine control
continent
partly incontinent (e.g. at night)
need help changing incontinence material
incontinent
Stool control
continent
partly incontinent (e.g. at night)
incontinent
Dressing / undressing
independent
needs support
completely in need of help
Eating / Drinking
independent
needs help e.g. when cutting
completely in need of help
Chewing and swallowing disorders
none
PEG tube
problems with fluid intake
has disorders
problems with food intake
Diet
none
yes
Description of diet
Sleeping problems
no problems
sporadically
disturbed sleep/wake cycle
Does the patient get up at night?
no
once
2 - 3 times
more than 3 times
night care / help with going to the toilet necessary
Additional information
Does he/she get sleeping pills?
no
yes
Current therapies
none
physical therapy
speech therapy
other
Description of therapy
What is the nature and character of the patient? (short description) (hobbies, daily routine, rituals such as getting up, going to bed and other, individual support)
Requirements and general conditions for the caregivers
Gender
women
male
doesn't matter
What expectations do you have of our employees? (character, characteristics, physical resilience)
General conditions
Location
big city - central
small town
rural
big city – suburbs
village
Living situation
single family house
apartment
Shopping (walking distance)
cca. 10 min
cca. 20 min
cca. 40 min
1 hour
longer then 1 hour
Facilities in the room for the employee
own bathroom
wardrobe
internet access
bed
radio
desk
TV
Notes
Work and leasure time arrangements
Organization of leasure time
2 hours a day and one day a week
2 hours a day and two half days a week
Duration of deployment
1 - 2 months
3 - 6 months
continuous
Planned start of deployment
Additional requirements
Pets
none
yes
Which pets
Cooking / meal preparation
always
occasionally
no
Laundry
always
occasionally
no
Ironing
always
occasionally
no
Accompaniment to doctor visits
always
occasionally
no
What else is important to you?
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