{"id":519,"date":"2023-03-31T11:45:32","date_gmt":"2023-03-31T09:45:32","guid":{"rendered":"https:\/\/websilver.pl\/?page_id=519"},"modified":"2023-03-31T11:46:16","modified_gmt":"2023-03-31T09:46:16","slug":"formularz-mozliwosc-przyjecia-pensjonariusza-2-2-2-2-2-2","status":"publish","type":"page","link":"https:\/\/websilver.pl\/index.php\/formularz-mozliwosc-przyjecia-pensjonariusza-2-2-2-2-2-2\/","title":{"rendered":"Formularz WS05 &#8211; za\u015bwiadczenie lekarskie"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"519\" class=\"elementor elementor-519\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1df6664 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"1df6664\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-e9a54f9\" data-id=\"e9a54f9\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-48a6e9b elementor-widget elementor-widget-shortcode\" data-id=\"48a6e9b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f518-o1\" lang=\"pl-PL\" dir=\"ltr\" data-wpcf7-id=\"518\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/519#wpcf7-f518-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formularz kontaktowy\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"518\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"pl_PL\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f518-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p><b>Formularz WS05 - <\/b> Za\u015bwiadczenie lekarskie o stanie zdrowia osoby ubiegaj\u0105cej si\u0119 o przyj\u0119cie do domu opieki\n<\/p>\n<p><mark>Niniejszy dokument jest dokumentem informacyjnym o stanie zdrowia pensjonariusza.<\/mark>\n<\/p>\n<p>1. Imi\u0119 i nazwisko pensjonariusza <i>(pole wymagane)<\/i>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n<\/p>\n<p>2. data urodzenia(pole wymagane)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"wiek\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"wiek\" \/><\/span>\n<\/p>\n<p>3. Adres zamieszkania<i>(pole wymagane)<\/i>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"adres\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"adres\"><\/textarea><\/span>\n<\/p>\n<p>4. Rozpoznanie choroby zasadniczej\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rozpoznanie_choroby\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"rozpoznanie_choroby\"><\/textarea><\/span>\n<\/p>\n<p>5. Przebieg schorzenia podstawowego\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"przebieg_choroby\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"przebieg_choroby\"><\/textarea><\/span>\n<\/p>\n<p>6. Uszkodzenia innych narz\u0105d\u00f3w i uk\u0142ad\u00f3w, choroby wsp\u00f3\u0142istniej\u0105ce\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"uszkodzenia\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"uszkodzenia\"><\/textarea><\/span>\n<\/p>\n<p>7. Rokowanie (mo\u017cliwo\u015b\u0107 poprawy), dalsze leczenie i rehabilitacja\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rokowanie\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"rokowanie\"><\/textarea><\/span>\n<\/p>\n<p>8. U\u017cywane zaopatrzenie ortopedyczne, \u015brodki pomocnicze i sprz\u0119t rehabilitacyjny,<br \/>\newentualne potrzeby w tym zakresie\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sprzet\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"sprzet\"><\/textarea><\/span>\n<\/p>\n<p>9. Wykaz wykonywanych bada\u0144 dodatkowych, konsultacji specjalistycznych, innej dokumentacji<br \/>\nmedycznej istotnej dla oceny stanu zdrowia\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"badania_dodatkowe\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"badania_dodatkowe\"><\/textarea><\/span>\n<\/p>\n<p>10. Zakres sprawowanej opieki i piel\u0119gnacji\n<\/p>\n<p>10.1.Sprawno\u015b\u0107 osoby: <i>(pole wymagane)<\/i>\n<\/p>\n<p>[checkbox* sprawnosc use_label_element \"le\u017c\u0105ca\" \n        \"porusza si\u0119 samodzielna\" \"porusza si\u0119 o kulach\" \"porusza si\u0119 na w\u00f3zku inwalidzkim\" \n        \"porusza si\u0119 z pomoc\u0105 drugiej osoby]\n<\/p>\n<p>10.2.Przyjmuje pokarmy: <i>(pole wymagane)<\/i>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pokarm\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"pokarm[]\" value=\"samodzielnie\" \/><span class=\"wpcf7-list-item-label\">samodzielnie<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"pokarm[]\" value=\"jest karmiona przez drug\u0105 osob\u0119\" \/><span class=\"wpcf7-list-item-label\">jest karmiona przez drug\u0105 osob\u0119<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"pokarm[]\" value=\"wymaga stosowania specjalnej diety\" \/><span class=\"wpcf7-list-item-label\">wymaga stosowania specjalnej diety<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>10.3.Specjalna dieta\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dieta\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dieta\"><\/textarea><\/span>\n<\/p>\n<p>10.4.Rodzaje ogranicze\u0144 czynno\u015bci:\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ograniczenia\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"ograniczenia[]\" value=\"mycie\" \/><span class=\"wpcf7-list-item-label\">mycie<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ograniczenia[]\" value=\"ubieranie\" \/><span class=\"wpcf7-list-item-label\">ubieranie<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"ograniczenia[]\" value=\"za\u0142atwianie czynno\u015bci fizjologicznych\" \/><span class=\"wpcf7-list-item-label\">za\u0142atwianie czynno\u015bci fizjologicznych<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>10.5.Inne ograniczenia\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"inne_ograniczenia\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"inne_ograniczenia\"><\/textarea><\/span>\n<\/p>\n<p>10.6.Rodzaj i cz\u0119stotliwo\u015b\u0107 zabieg\u00f3w piel\u0119gnacyjnych wykonywanych w ci\u0105gu dnia\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"zabiegi_pielegnacyjne\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"zabiegi_pielegnacyjne\"><\/textarea><\/span>\n<\/p>\n<p>10.7.Rodzaje i liczba zabieg\u00f3w rehabilitacyjno \u2013 leczniczych wykonywanych w domu i poza domem w<br \/>\nci\u0105gu dnia, tygodnia lub miesi\u0105ca\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"zabiegi_rehabilitacyjne\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"zabiegi_rehabilitacyjne\"><\/textarea><\/span>\n<\/p>\n<p>10.8.Cz\u0119stotliwo\u015b\u0107 wizyt lekarskich w domu, poza domem, w tygodniu lub w miesi\u0105cu\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"wizyty_lekarskie\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"wizyty_lekarskie\"><\/textarea><\/span>\n<\/p>\n<p>11. Czy aktualnie stwierdza si\u0119:\n<\/p>\n<p>11.1.Chorob\u0119 zaka\u017an\u0105 (jak\u0105)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"choroba_zakazna\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"choroba_zakazna\"><\/textarea><\/span>\n<\/p>\n<p>11.2.Chorob\u0119 weneryczn\u0105 (jak\u0105)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"choroba_weneryczna\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"choroba_weneryczna\"><\/textarea><\/span>\n<\/p>\n<p>11.3.Utrat\u0119 wzroku (jaki stopie\u0144)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"utrata_wzroku\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"utrata_wzroku\"><\/textarea><\/span>\n<\/p>\n<p>11.4.Padaczk\u0119\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"padaczka\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"padaczka\"><\/textarea><\/span>\n<\/p>\n<p>11.5.Chorob\u0119 psychiczn\u0105 (jak\u0105)\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"choroba_psychiczna\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"choroba_psychiczna\"><\/textarea><\/span>\n<\/p>\n<p>11.6.Czy chory mo\u017ce by\u0107 niebezpieczny dla siebie?\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"niebezpieczny_dla_siebie\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"niebezpieczny_dla_siebie[]\" value=\"TAK\" \/><span class=\"wpcf7-list-item-label\">TAK<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"niebezpieczny_dla_siebie[]\" value=\"NIE\" \/><span class=\"wpcf7-list-item-label\">NIE<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>11.7.Czy chory mo\u017ce by\u0107 niebezpieczny dla innych?\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"niebezpieczny_dla_innych\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"niebezpieczny_dla_innych[]\" value=\"TAK\" \/><span class=\"wpcf7-list-item-label\">TAK<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"niebezpieczny_dla_innych[]\" value=\"NIE\" \/><span class=\"wpcf7-list-item-label\">NIE<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>11.8.Dlaczego chory mo\u017ce by\u0107 niebezpieczny\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"niebezpieczny_dlaczego\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"niebezpieczny_dlaczego\"><\/textarea><\/span>\n<\/p>\n<p>12. Uwagi uzupe\u0142niaj\u0105ce i zalecenia lekarza\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"uwagi\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"uwagi\"><\/textarea><\/span>\n<\/p>\n<p>13. Tw\u00f3j adres e-mail <i>(pole wymagane)<\/i>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n<\/p>\n<p><mark>Wszelkie uwagi i korespondencj\u0119 prosimy o wysy\u0142anie na adres e-mail podany w sekcji Kontakty w serwisie www.websilver.pl<\/mark>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Wy\u015blij\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"42\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-519","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/pages\/519","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/comments?post=519"}],"version-history":[{"count":3,"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/pages\/519\/revisions"}],"predecessor-version":[{"id":522,"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/pages\/519\/revisions\/522"}],"wp:attachment":[{"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/media?parent=519"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}