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Quel est votre statut professionnel actuel ? [_] Actif Dans ce cas, quelle profession exercez-vous ? Retraité Dans ce cas, A quel âge avez-vous pris votre retraite ? ,
s) pathologie(s) ?, avez-vous la CMU (couverture maladie universelle) ? OUI [_] NON ,
Une prestation relative à une invalidité ou à un handicap (AAH, Pension d'invalidité, minimum invalidité, AES) [_] Rentes accident du travail et maladie professionnelle [_] Minimum vieillesse [_] Prestation dépendance (APA, PSD) [_] Aides financières au logement [_] Autres (dont allocation veuvage, congés maladie longue durée) Précisez :Quel est le montant total mensuel des prestations dont vous bénéficiez ?, Quelles sont la ou les prestations que vous percevez actuellement avez vous une ou des pathologies (ex : HTA, Diabète, insuffisance cardiaque, dépression?) ? Oui [_] Non ,
Consommations de toxiques Parmi les substances ci-dessous, avez-vous déjà utilisé l'une d'entre elles ? ,
Combien de cigarettes par jour actuellement, ) : Oui [_] Non ,
Au cours de cette semaine (7 jours précédents), avez-vous consommé des médicaments ? Ne pas oublier les pilules, autres contraceptifs, somnifères, antalgiques, injections, vaccins, patch, crèmes, pommades etc ,
Donnez le nom précis de ces médicaments, leur dosage, le problème de santé pour lequel vous avez pris ce médicament, s'il a été prescrit ou s'il s'agit d'automédication, la quantité consommée ? Au cours des 12 derniers mois avez-vous bénéficié d'une prise en charge paramédicale à domicile ? OUI ,
Kinésithérapeute Nombre de prises en charge : _ _ _ _ _ _ _ par semaine ,
Donner les points de départ et d'arrivée ou donner le nombre approximatif de kilomètres des transports (un aller-retour=2 transports) ,