Rehabilitation questionnaire
GHA Medical Travel Professional

Welcome to rehabilitation questionnaire

Medical questionnaire is crucial in evalution of client's health condition and proposing a proper medical treatment. Please fill that medical queationnaire below which is related to what kind of medical care you are looking for so we can start the process of the medical care as soon as possible.



Rehabilitation Questionnaire

01

GENERAL INFORMATION

02

ADDITIONAL INFORMATION

03

SPECIFICATION OF THE PATIENT'S MEDICAL CONDITION

04

FOR THE QUESTIONS BELOW, PLEASE SELECT THE RELEVANT OPTION

Self-sufficiency

a.
b.
i.
ii.
iii.
iv.
v.
vi.
c.
i.

Motion - walking

a.
b.
c.
d.
e.
f.
i.
ii.
g.

Cooperation in rehabilitation

a.
b.
c.

Orientation

a.
b.
c.
d.

Communication

a.
b.
c.
d.

Urination

a.
b.
c.

Bowel function

a.
b.
05

YOUR SPECIAL REQUIREMENTS AND ANY OTHER INFORMATION YOU CONSIDER IMPORTANT

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