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Home
About Us
Our Gallery
Our Services
Stroke Rehabilitation
Dementia Care
Palliative Care
Our Locations
Klang
Kajang
Petaling Jaya
Puchong
Johor Bahru
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Home care request form
Please fill out all the form fields below in order for our care professionals to provide you with a precise cost estimate. Need help with this? Call us at +6012-321 0457 for assistance.
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What is the requester's name?
*
Requester's email address:
*
Requester's phone no.:
What is the care recipient's name?
*
Location where care services are needed:
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Age
*
Gender
*
Male
Female
Approximate height (in cm)
Approximate weight (in kg's)
Days when services are required:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hours per day services are required:
*
What is the client's mobility level?
*
Independent (Ambulates independently, may require the use of aids for weight bearing support. Does not require much assistance )
Semi-dependent (Mostly confined to a wheelchair, will need assistance with weight bearing and activities of daily living)
Fully dependent (Bed-ridden. Maximum assistance required for activities of daily living)
Level of toileting assistance required:
*
Independent
Uses of an urinal
On diapers
On a urinary catheter
Requires stoma care
Assistance required for personal grooming:
*
Not required as client is able to manage own personal grooming needs
Yes, assistance is required
Level of assistance required with feeding:
*
Not needed as client can manage feeding independently
Yes spoon feeding needed
Client is on parenteral feeding ( NG tube / PEG tube)
Food preparation:
*
Food is prepared by the family
Need assistance to heat-up and serve pre-prepared food
Requires Genesis to assist with food preparation
Level of alertness
*
Alert and responsive
Alert but un-responsive
Not alert nor responsive
Does the client display any aggressive tendencies towards attending caregivers?
*
Yes
No
Has the client been diagnosed with any form of mood or psychiatric disorders?
*
Yes
No
Does the client have any requirements for special medical procedures?
Wound care
Tracheostomy care
Stoma care
Urinary catheter change
Nasogastric tube change
Type of equipment available at home:
Hospital bed
Wheelchair
Quadricane
Walking stick
Suction machine
Ripple mattress
Oxygen concentrator
Other relevant information
Submit
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Home
About Us
Our Gallery
Our Services
Stroke Rehabilitation
Dementia Care
Palliative Care
Our Locations
Klang
Kajang
Petaling Jaya
Puchong
Johor Bahru