טופס תפקודים לקביעת מתן עזרה סיעודית וסידור מוסדי – באנגלית להורדה, הדפסה ומילוי מקוון

This document is titled "Form for Determination of the Provision of Nursing Care and Institutional Accommodations," and its purpose is to assess an individual's eligibility for nursing care and institutional accommodations provided by the Israeli Ministry of Defense, Department of Families, Commemoration, and Heritage.

Sections of the form include:

1. Applicant Personal Details:
- First Name
- Last Name
- Israeli ID / Passport Number
- Address
- City
- Country
- Current Medical Diagnosis

2. Movement Assessment:
- Walks independently or with assistance
- Use of mobility aids (cane, walker, wheelchair)
- Bedridden status

3. Dressing Assessment:
- Independence level (independent, partial assistance, full assistance)

4. Bathing Assessment:
- Independence level (independent, partial assistance, full assistance)

5. Eating Assessment:
- Independence level (independent, partial assistance, full assistance)

6. Vision Assessment:
- Vision status (normal, normal with glasses, blind in one eye, visually impaired, blind)
- Requirements for applicants under/over 75 years

7. Bowel and Bladder Control:
- Control level for bowel and bladder functions
- Use of absorbent products

8. Supervision due to Dementia / Mental State:
- Level of impairment
- Required supervision
- Potential danger to self or others

9. Estimated Time to Recovery:
- Recovery timeframe

10. Summary and Functional Evaluation:
- Frailty level
- Emotional frailty
- Need for nursing care
- Independence level
- Age-specific diagnosis requirements

11. The Main Functional Disabilities of the Patient: Describe the patient's main functional disabilities.

12. Recommendation:
- Referral for a nursing home-based arrangement
- Staying at home with required assistance

13. Living Accommodations:
- Whether the applicant lives alone or with others

14. Physician's Details:
- Nurse's Name
- Physician's Name
- Physician's stamp with license number
- Signature

This form is used to assess an individual's medical and functional status to determine their eligibility for nursing care and institutional accommodations provided by the Israeli Ministry of Defense. The form is comprehensive and requires input from medical professionals.