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Questionnaire

For patients to be admitted to neurological rehabilitation

High quality in neurological
rehabilitation Patient´s details

    This form can be completed by the patient, a relative or the attending physician.

    General information

    *Are you the patient?
    If you are not the patient, please provide your contact details
    * Mandatory Fields

    Patient Details

    Please provide your/the patient's details

    Disease/Diagnosis

    Please provide us with the diagnosis you/the patient is looking to be treated for.

    Current stay of the patient

    Where is the patient currently located?

    Barthel-Index

    The Barthel Index is an assessment method for basic everyday functions, so-called Activities of Daily Living (ADL). Please answer the following questions to the best of your knowledge, they are used to determine in which phase the patient needs to be treated:
    1. Does the patient’s condition require 24/7 monitoring of vital signs?
    2. Does the patient have a tracheostoma / tracheostomy tube?
    3. Does the patient require mechanical ventilation?
    4. Does the patient have an orientation disorder? (Impairment in recognising or understanding one’s current situation and or events etc.)
    5. Does the patient have a behavioural disorder? (anxiety, aggression, restlessness, depression, sleep disorder, eating disorder etc.)
    6. Does the patient have a communication disorder? (Deficit in hearing, speech and/or language)
    7. Does the patient have a swallowing disorder?
    8. Eating and drinking (with assistance, if food is cut up small before eating)
    9. Getting from wheelchair to bed and vice versa (including: sitting up in bed)
    10. Personal hygiene (washing face, combing hair, shaving, brushing teeth)
    11. Going to the toilet (Putting on/off clothes, wiping oneself properly, flushing the toilet)
    12. Taking bath or shower
    13. Walking on the flat
    14. Going up/down stairs
    15. Dressing/undressing (including: tying shoelaces, fastening buttons)
    16. Bowel control
    17. Bladder control

    Additional Questions

    Is the patient fitted with:

    Does the patient have:

    Collaboration with staff:

    When engaging with medical staff, the patient:

    Current medication

    Please provide us with the current medication of the patient.

    Treatment Costs:

    Who will be covering the treatment cost?

    Where will the patient continue treatment after discharge from Kliniken Schmieder?



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