Get help – Revived Soldiers Ukraine

Personal and contact information

Name: *

Date of birth: *

Age: *

Email:

Phone number: *

Country: *

Label: *

City: *

Home Address: *

Are you a military person (are / were) or a civilian?: *

If a military person (ATO / OOS participant), series and number of UBD or other version of the certificate: *

How did you find out about us?:

Where he served (brigade):

Contact details of the person (relative, friend, etc.), in case of emergency:

Name *

Who he (she) is for you: *

Phone number: *

Medical Information

Complete medical diagnosis: *

Date of injury: *

Are there any concomitant diseases? What (hypertension, hypotension, diabetes, cardiovascular disease, allergies, bronchial asthma, inflammation of the bladder or kidneys, seizures, etc.): *

Have you been rehabilitated before? If so, where and when? *

Presence of probe, gastrostomy, tracheostomy, etc.: *

Do you have deposits or other wounds (localization): *

Do you have contractures (specify where): *

Are there any contraindications to exercise: *

Indicate all medications you are currently taking, including type of medication, dosage and why (function): *

Can you complete the following tasks? Self-service:

Meal

Do it yourself

Perform in part or with

Performed by another person

Dressing / undressing the upper body

Do it yourself

Perform in part or with

Performed by another person

Dressing / undressing the lower body

Do it yourself

Perform in part or with

Performed by another person

Taking a bath / shower

Do it yourself

Perform in part or with

Performed by another person

Toilet

Do it yourself

Perform in part or with

Performed by another person

Can you complete the following tasks? Mobility:

Return to bed (on the sides, abdomen)

Do it yourself

Perform in part or with

Performed by another person

Move from lying to sitting position

Do it yourself

Perform in part or with

Performed by another person

Moving from bed to cart and vice versa

Do it yourself

Perform in part or with

Performed by another person

Moving to the toilet

Do it yourself

Perform in part or with

Performed by another person

Can you complete the following tasks? Moving within the house:

On the cart

Do it yourself

Perform in part or with

Performed by another person

With aids (sticks, crutches, walkers)

Do it yourself

Perform in part or with

Performed by another person

Independently (without aids)

Do it yourself

Perform in part or with

Performed by another person

Can you complete the following tasks? Moving away from home:

On the cart

Do it yourself

Perform in part or with

Performed by another person

With aids (sticks, crutches, walkers)

Do it yourself

Perform in part or with

Performed by another person

Independently (without aids)

Do it yourself

Perform in part or with

Performed by another person

Date of completing the questionnaire: *

If you have any questions, send us your message and we will answer you as soon as possible

Name:

Phone:

Email:

Question:

Or call the number: 068 740 72 62