Beit Rafqa
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Assessment Questionnaire

Please complete all of the sections in this form. Once received we shall contact you to discuss your requirements.

About You
 First Name
 Family Name
 Email
 Telephone
 Mobile
Your Relationship to Dependent
About Your Dependent
 Full Name
 Date of Birth
 Gender
 Marital Status
 Current Living Arrangements
 Medical History
 Previous Surgeries Performed:
 Date




 Surgery



 Chronic Diseases:
 Diabetes Cholesterol Hypertension Heart Disease
 Kidney Disease Hepatitis Epilepsy Hemiplegia
 Others
 Allergies
 Medications taken Regularly:
 Medicine



 Dose



 Schedule



 General Information
 Level of Assistance Required
 Ability to Eat
 Ability to dress
 Ability to bath and care for personal hygiene
 Ability to transfer and move
 Ability to self administer medication
 Special Equipment Needed:
 Bed Rails Brace Cane Wheelchair
 Other
 Habits:
 Smoker Alcohol
 Other
 Hobbies & Special Interests:
 Arts & Crafts Writing Gardening Musical Instrument
 Other
 Contacts
 Family Physician:
 Name
 Telephone
 Address
 Email
 Substitute Decision Maker:
 Name
 Telephone
 Email
Relationship to Dependent
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