Patient health questionnaire (Care and rehabilitation for the elderly)

Please fill in a patient health questionnaire. Our consultant will contact you and present the details of hospitalisation for the elderly.

Patient's date of birth *
Contact details of a relative *
Was the patient ill within the last 12 months? *
If yes, please specify the diseases. *
Was the patient hospitalised within the last year? *
If yes, please specify the reason. *
What operations has the patient had in the past 12 months? *
State all chronic diseases the patient used to have or still is suffering from. *
Is the patient allergic to anything? If yes, please specify the substance. *
Please enumerate all medicinal products the patient has been currently taking. *
Is the patient vaccinated against: tetanus, hepatitis A, and hepatitis B? *
Does the patient walk using crutches, walker or are they bedridden? *
Is the patient self-independent or do they require help of third parties while dressing up, feeding, washing, physiological functions? *
Does the patient have urination problems and does the patient require diapers/other special personal hygiene products constantly? *
* - Required field