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"There's no place like home"
Domestic help for persons
in need of care.
Form
1 / 7
Beneficiary - one or two persons (living in the same household):
Name
Surname
Date of birth
Street and house number
Town
Postal code
Martial status
Telephone number
Mobile phone number
e-mail
person_add
Second person
Name
Surname
Date of birth
Mobile phone number
2 / 7
Contact person
Name
Surname
Street and house number
Town
Postalcode
Telephone number
Mobile phone number
e-mail
3 / 7
Information on the beneficiary and household
Relatives
Live in the same household
Come to visit (how often)
Health characteristics
Alzheimer
Bedbound
Multiple sclerosis
Walking impaired
Permanent catheter
Problems with the oesophagus
Hearing loss
Cardiovascular diseases
Cancer
Decubitus (pressure ulcer)
Incontinence
Mentally handicapped
Dementia
Stoma (intestinal outlet/urine diversion)
Incontinence aid carrier
High blood pressure
Diabetes
Parkinson
Other diseases, please specify
Surveillance at night
No
If so, how should this be done?
Night sleep
Undisturbed
Occasionally disturbed
Often considerable restlessness
Regular night-time care
Disorientation
in time
personal
in place
Fitness
The person being cared for does not have to be lifted
The person being cared for must be lifted
The person being cared for can help
Help equipment at the location
Lifting strap
Lifting seat
Patient lift
others
Household work
Basic cleaning necessary on arrival
Ironing
Cleaning up
Cooking? If so for how many?
Washing
Shopping
Areas to keep clean
others (please list)
Garden available
yes
no
Interet available
yes
no
Light gardening
yes
no
House
Flat/apartment
Pets? If yes, which ones?
4 / 7
Benefits for the caregiver (with free accommodation and meals at all times)*
Free time (depending on possibility and arrangement)
Hourly daily free time
a full day off per week
one full weekend off per month
Long term holidays by arrangement
5 / 7
Expectations of the caregiver (with ability to communicate)
Starting date
Expected duration of stay
Age
25-30
30-40
40-50
50-60
irrelevant
Gender
Woman
Man
irrelevant
Strong person
irrelevant
Yes, because patient is heavy
Driving licence with experience
yes, important
gladly welcomed
irrelevant
References
yes, important
gladly welcomed
irrelevant
Non-smoker
Yes
irrelevant
Animal lover
yes, please
irrelevant
6 / 7
Conditions
Apart from a room of her own, the caregiver has
A separate bathroom
Shares a bathroom with the residents of the house
Internet access
Telephone access
own TV set
7 / 7
Incidental duties as a caregiver (other than typical household activities)
Daily help with the
Washing
Getting dressed
Food consumption
Light nursing duties
having a walk
with cane
With walking aid
in a wheelchair
Daily care
active care
Changing diapers
Others
Ability to communicate
Fully communicative
Imparied with
Vision
Hearing
Speaking
Understanding
I certify that the information provided above is complete and correct. Incorrect or incomplete information may result in additional costs or termination of the contract. -Both parties state, to treat the agreements made in this contract as confidential and not to pass them on to third parties.
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