Url SECTION A: FACILITY SELECTION EDEN Kuching EDEN Sg Buloh SECTION B: SERVICE REQUIRED Long-term assisted living care Short-term Respite Care Convalescence (Post-hospital care) Skilled Nursing Care (bedridden/tube feeding/wound care) Dementia Care Senior Day Care SECTION C: PERSON WHO NEEDS CARE INFORMATION Name * Age * Gender * Please select Female Male SECTION D: CURRENT RESIDENCE INFORMATION At Home At Hospital At Nursing Home Current Home Address * Nursing Care Facility * Hospital * SECTION E: PHYSICAL CONDITION Does this person wear diapers? * No Yes Does this person have wound? * No Yes (Pressure sores, Injury, Deep abrasions, Puncture wounds, Animal bites, Others) Does this person use urine catheter? * No Yes Does this person use nasogastric tube (Feeding tube) * No Yes Does this patient have a risk of fall? * No Yes Does this person require assistance with bathing? * Yes, fully dependent Yes, requires partial assistance No, independent Does this person require assistance with toileting? * Yes, fully dependent Yes, requires partial assistance No, independent Does this person need help transferring from bed to chair? * Yes, fully dependent Yes, requires partial assistance No, independent Does this person require assistance with walking? * Yes, fully dependent Yes, requires partial assistance No, independent Does this person require assistance with eating and drinking? * Yes, fully dependent Yes, requires partial assistance No, independent Does this person use or require any of the following assistive devices? (Please select all that apply) * Walking stick Walking frame (walker) Crutches Wheelchair Shower chair SECTION F: MEDICAL CONDITION Which of the following conditions are you (patient) currently being treated or have been treated for in the past (Please select all that apply): * High blood pressure Diabetes High cholesterol Dementia (including Alzheimer's disease) Neurological problems (Parkinson disease) Stroke Arthritis Heart disease / Murmur / Angina Lung problems / cough Kidney / Bladder problems Prostate Problems Shortness of breathe Asthma Eye disorder / Glaucoma Osteoporosis Depression / Anxiety Heartburn (reflux) Seasonal allergies Cancer Anemia or blood problems Seizures Ulcers/colitis Ear problems Thyroid problems Psychiatric care Other Other (medical condition) SECTION G: DIETARY NEEDS What type of food does the person typically consume? * Normal (regular food) Cut into small pieces Soft food (easy to chew) Pureed Does the person have difficulty swallowing (dysphagia)? * Yes No Section H: CONTACT PERSON Name * Email * Contact No. * Relationship with people who needs care * By completing this form, I confirm that the information provided is accurate and true to the best of my knowledge. I understand that this information will be used by the care facility to assess the appropriate care plan for the patient.
