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, Annexe 2 : questionnaire SORTAVI SORTAVI NOM Prénom : Date prévue de l'implantation : Date de l'appel, Personne jointe et N° : Remarque : Lieu de vie : ? Seul ? Avec : Remarque : ? Domicile personnel ? Institution Remarque : Domicile personnel : ? Maison : Plain-pied ou étage ? Si étage, vol.24, pp.257-64, 2017.

?. Appartement, Quel étage ? Ascenseur ? Combien de fois par jour montez-vous les escaliers ? Remarque : Mode de sortie à prévoir

, ? Retour possible au domicile à J4/J5 (patient assez dépendant, mais avec entourage suffisamment présent ou disponible pour envisager un retour après une bonne ré-autonomisation en intra-hospitalier

, Au moment d'être admise à exercer la médecine, Mesures à prendre : ? Demande de convalescence ? Intervention assistance sociale : ? Contacter CHG / ? Contacter famille : ? Autre Remarques : Serment d'Hippocrate

, Mon premier souci sera de rétablir, de préserver ou de promouvoir la santé dans tous ses éléments, physiques et mentaux, individuels et sociaux

, Je respecterai toutes les personnes, leur autonomie et leur volonté, sans aucune discrimination selon leur état ou leurs convictions. J'interviendrai pour les protéger si elles sont affaiblies, vulnérables ou menacées dans leur intégrité ou leur dignité. Même sous la contrainte

, Je ne tromperai jamais leur confiance et n'exploiterai pas le pouvoir hérité des circonstances pour forcer les consciences

, Je ne me laisserai pas influencer par la soif du gain ou la recherche de la gloire

, Admise dans l'intimité des personnes, je tairai les secrets qui me seront confiés. Reçue à l'intérieur des maisons, je respecterai les secrets des foyers et ma conduite ne servira pas à corrompre les moeurs

, Je ne prolongerai pas abusivement les agonies. Je ne provoquerai jamais la mort délibérément

, Je n'entreprendrai rien qui dépasse mes compétences. Je les entretiendrai et les perfectionnerai pour assurer au mieux les services qui me seront demandés

, J'apporterai mon aide à mes confrères ainsi qu'à leurs familles dans l'adversité

, Que les hommes et mes confrères m'accordent leur estime si je suis fidèle à mes promesses

, que je sois déshonorée et méprisée si j'y manque