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Who we are
Our History
Management of the Kliniken Schmieder
Clinics
Allensbach
Range of Services
Medical Specialties
Our Team
Our Medical Team
Patient Rooms
How to Get Here
FAQ
Heidelberg
Range of Services
Medical Specialties
Our Team
Our Medical Team
Patient Rooms
How to Get Here
FAQ
Gailingen
Range of Services
Medical Specialties
Our Team
Our Medical Team
How to Get Here
FAQ
Konstanz
Range of Services
Medical Specialties
Our Team
Our Medical Team
How to Get Here
FAQ
Gerlingen
Range of Services
Medical Specialties
Our Team
Our Medical Team
FAQ
How to Get here
Stuttgart
Day Clinic
Outpatient Therapy Centre
Satellite Ward of the Stuttgart Clinic
How to Get Here
Our medical services
Neurological diseases
Stroke
Traumatic Brain Injury
Multiple sclerosis
Parkinson’s disease
Epilepsy
Polyneuropathy
Chronic pain
Cerebral palsy in adults
Coronavirus COVID-19
Long COVID
Brain tumors
Spinal trauma
Peripheral nerve damage
Neuropathic pain
Sleep disorders
Alzheimer’s disease
Lyme disease
Guillain–Barré syndrome
Encephalitis (inflammation of the brain)
Diagnostic
Diagnostic packages
Digital Consultation
Therapy
Saebo Flex
CIMT
Gait Training
Brain Stimulation Centre (BSC)
Department of Neuroradiology and Radiology
Early Neurological Rehabilitation
Centre for Sleep Medicine
Post-COVID-19 Rehabilitation Programme
Expertise
International patients
Patient reports
International patients
Partners
Embassies
Insurance and assistance companies
Medical tourism facilitators
Regional partners
Patients and Companions
5 Steps to Kliniken Schmieder
Information about COVID-19
Downloads
FAQ
Lurija Institute
Zenith
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Call us +49 7533 8081533
Send us a Whatsapp message
Email us
Call us +49 7533 8081533
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Questionnaire
For patients to be admitted to neurological rehabilitation
High quality in neurological
rehabilitation Patient´s details
Patient´s details
Name
Address
Date of birth
Contact person
Parents
Yes
No
Unknown
Spouse/partner
Yes
No
Unknown
Children
Yes
No
Unknown
Take care of patient
Yes
No
Unknown
Address contact person
Name
Street address
Zip code
Place of residence
Phone
Costs paid by
Statutory health insurance company (HIC)
Private HIC / Self-payer
Employer‘s liability insurance association/ accident insurance company
Annuity insurance company
Social welfare authority
Address
Diagnosis /diagnoses
1
2
3
4
Guardian
Transferred from
Regular ward
Nursing Home
Intensive care unit
Home
Return possible
Yes
No
Unknown
Onset of disease / day of accident
Complications
Seizures
Generalised
Focal
Unknown
Instable fractures
Yes
No
Unknown
Heterotopic ossifications
Yes
No
Unknown
Algodystrophy
Yes
No
Unknown
Contractures
Yes
No
Unknown
Infections
Yes
No
Unknown
Multidrug resistant organisms (MDRO)
Positive
3x negative
Unknown
Provided with
Tracheostoma
Pacemaker: type
Central venous catheter
Shunt: type
Urinary catheter
suprapubic
transurethral
intermittent
PEG
Other tube
Wheelchair
active
electronic
Rollator
Foream crutches
Walking stick
Prostheses: Extremity prostheses
Endoprostheses
cemented
uncemented
Osteosynthesis
Malfunction
Aphasia
Dysarthria
Dysphagia
Disturbance of orientation
Neuropsychological disorder
Behaviour disorder
Depression
Psychosis
Risk of suicide
Hearing disorder
Manifest addiction
Neglect
Visual disturbance:
Hemianopsia
Amaurosis
Others
Fracture
Load-bearing capacity
kg
Urinary catheter
suprapubic
transurethral
intermittent
PEG
Other tube
Collaboration in care and therapy
Shows own initiative
Active
Passive
Reluctant
Further treatment
Not settled
Settled
Where could the patient be transferred to after his/ her treatment in our hospital if (s)he cannot be dismissed
to his/ her home? [must be filled in necessarily]
Address
Phone
Contact
1. Patient’s condition must be monitored in the intensive care unit
Yes
No
Unknown
2. Tracheostoma
Yes
No
Unknown
3. Intermittent ventilation
Yes
No
Unknown
4. Disturbance of orientation (confusion)requires supervision
Yes
No
Unknown
5. Behaviour disorder requires supervision (including threatening patient‘s own life or life of others, e.g. manifest suicidality
Yes
No
Unknown
6. Severe communication disorder
Yes
No
Unknown
7. Dysphagia requiring supervision
Yes
No
Unknown
8. Eating and drinking (with assistance, if food is cut up small before eating)
not possible
with assistance
without assistance
Unknown
9. Getting from wheelchair to bed and vice versa (including: sitting up in bed)
not possible
with major assistance
with minor assistance
without assistance
Unknown
10. Personal hygiene (washing face, combing hair, shaving, brushing teeth)
not possible
without assistance
Unknown
11. Going to the toilet (Putting on/off clothes, wiping oneself properly, flushing the toilet)
not possible
with assistance
without assistance
Unknown
12. Taking bath or shower
not possible
without assistance
Unknown
13. Walking on the flat
not possible
wheelchair independent
with major assistance
without assistance
Unknown
14. Going up/down stairs
not possible
with assistance
without assistance
Unknown
15. Dressing/undressing (including: tying shoelaces, fastening buttons)
not possible
with assistance
without assistance
Unknown
16. Bowel control
not possible
with assistance
without assistance
Unknown
17. Bladder control
not possible
with assistance
without assistance
Unknown
Current medication
IMPORTANT:
To be able to provide uninterrupted treatment and to plan an optimum therapy we ask you to make sure that the
patient brings all
medical reports, findings etc. (particularly X-ray, CT and NMR images) which you have received, AND the current medication
when admitted to our hospital!
Transferring physician / institution
Phone
Send