Questionnaire for elderly people: my health and care needs

Your relative has been admitted to UZ Leuven. Since visits are no longer allowed due to COVID-19 measures, we would like to ask you to complete this online questionnaire to give us an idea of your relative's medical condition (physical and mental functioning, diet and social condition, etc.) prior to his/her admission to the hospital.

If you have any issues completing the questionnaire, feel free to send us an email.

I am

We sturen een kopie van deze inzending naar het opgegeven e-mailadres.

My relative has been admitted to
Social context
Civil status

Family situation

Living situation

I currently live
I live in a
In which type of permanent home care do you live?

Social relations

Are you responsible for the care of (a) person(s)?

We would like to have an idea of how you functioned before your admission to hospital. Please indicate below what applies to you.

Self care

specify further
Getting dressed in the morning
specify further
Getting dressed in the evening
specify further


Getting in and out of bed
Do you have a hospital bed?
If yes, do you use a grab handle?
specify which
I use these walking aids
If you are wheelchair-bound, can you move around independently with this wheelchair?


Are there doorsteps or stairs to the entrance of your accommodation?
Are there any doorsteps or stairs in the accommodation (to cellar, to top floor, etc.)?
If necessary, can you avoid taking the stairs in your accommodation?


Going to the toilet
Specify further
Is there a toilet on the same floor where you sleep?


Do you sometimes unintentionally suffer urine loss?
Do you have a catheter?
Do you sometimes unintentionally suffer bowel incontinence?
Do you have a stoma?
Do you use one of the following incontinence materials?


Have you started eating less over the past three months?
Have you unintentionally lost weight over the past three months?
Do you often choke on
Do you follow one of the following diets?
Do you drink alcoholic beverages?

How many glasses ... do you drink per day?

Do you smoke?

How many ... do you smoke per day?


I use the telephone independently
I do my (grocery) shopping independently
I cook hot meals independently
I do the housework independently
I do the laundry myself
I get around independently by bicycle, car or public transport
I take my medication independently
Do you experience difficulties when taking your medication (forget, mistake, etc.)?
Who prepares your medication?
Do you use a medication box to prepare your medication?
I manage my money myself
Has an administrator or representative been appointed?


Do you have a personal alarm system?
Were you in pain before your hospitalisation?
If yes, was the pain
When were you in pain?
Did the pain affect your everyday functioning?
Do you sleep well in general?
If no:
Do you use sleep medication?
Mental functioning


Have you often felt sad, depressed or hopeless over the past month?
Over the past month were you often not interested in things or could you not enjoy them?
If yes, do you want help for this?


Do you regularly forget things?
Have you experienced a period of abnormal confusion recently?
Have you already had a memory test?


Have you noticed any changes in your behaviour (e.g. more anxious, restless, etc.) lately?
Do you hear or see things that are not there?
Are you sometimes restless or confused at night?
Meaning and rituals
Do you feel your life currently lacks meaning?
Do you feel a lot of pain at the loss of a loved one?
Do you worry about the loss of your capabilities and/or home environment?
Do you wish to receive the anointing or blessing of the sick?
Expectations after hospitalisation
What do you expect after the hospitalisation?
Have any preventive requests for admission to a residential care centre already been made?
Contact details


Write the details of your most important contacts here below. At the top, put the person who can be contacted first during the admission. Indicate who can be notified at night in case of problems.

Contact 1
Notify at night
Contact 2
Notify at night
General Practitioner

Home care support

Which home care support did you already receive before your admission to hospital?

Type of help

E.g. massage, walking, remedial therapy: exercises arms and legs, etc.

E.g. Home adaptations, advice aids, etc.

E.g. cooking, help washing or getting dressed, shopping, cleaning, etc.

E.g. mowing the grass, weeding, plumbing, etc.

E.g. cooking, shopping, ironing, keeping company, etc.

Eg. massage, walking, excercises for arms and legs, ...

Comments or questions
Last edit: 24 May 2022