Personal assistants for the elderly

First and Last name *

Phone *

E-mail *

Town *

Region *

Age *

Sex

Woman

Man

Does he live alone?

Yes

No

Primary disease *

Comorbidities

Is there dementia?

Degree of mobility

Approximate weight of the person being cared for

Is lifting or moving necessary?

What bed does he use?

Toilet

None

Walking stick

Walker

Crutches

Wheelchair

Toilet chair

Others

Yes, sleep well.

Wakes up sometimes

No, it happens often.

No

1–2 times

More than 2 times

No

Only at night

Yes, 24/7

Personal hygiene

Diaper change

Food preparation

Nutrition

Shopping

Walks

Society

Accompanying

Taking medication

Other

Duration

How many days a week?

Since when do you need an assistant?

No

Yes

Please describe everything you consider important so that we can offer you the most suitable assistant.

Personal assistants for the elderly

Personal data

Information about your loved one

Health status

What help does he need?

What kind of care are you looking for?

Do you have a pet?

Additional information