{"id":4814,"date":"2024-11-25T19:26:14","date_gmt":"2024-11-25T18:26:14","guid":{"rendered":"https:\/\/app.lux-solution.de\/opwb73t\/?page_id=4814"},"modified":"2026-03-12T11:16:02","modified_gmt":"2026-03-12T10:16:02","slug":"pflegerische-aufnahme","status":"publish","type":"page","link":"https:\/\/app.lux-solution.de\/opwb73t\/pflegerische-aufnahme\/","title":{"rendered":"Pflegerische Aufnahme"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"4814\" class=\"elementor elementor-4814\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d460d16 e-flex e-con-boxed e-con e-parent\" data-id=\"d460d16\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ec8b1f2 elementor-widget elementor-widget-shortcode\" data-id=\"ec8b1f2\" 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\">\t\t<div data-elementor-type=\"container\" data-elementor-id=\"5373\" class=\"elementor elementor-5373\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t<div class=\"elementor-element elementor-element-43313cd0 e-flex e-con-boxed e-con e-child\" data-id=\"43313cd0\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-21cfbae e-flex e-con-boxed e-con e-child\" data-id=\"21cfbae\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2a2f7686 elementor-widget elementor-widget-heading\" data-id=\"2a2f7686\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Universit\u00e4tsklinikum Freiburg<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-title-color=\"#7A7A7A\" class=\"elementor-element elementor-element-720d980 elementor-widget elementor-widget-heading\" data-id=\"720d980\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-heading-title elementor-size-default\">Klinik f\u00fcr Urologie<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-title-color=\"#7A7A7A\" class=\"elementor-element elementor-element-2dec4b64 elementor-widget elementor-widget-heading\" data-id=\"2dec4b64\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-heading-title elementor-size-default\">Hugstetter Str. 55<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-title-color=\"#7A7A7A\" class=\"elementor-element elementor-element-eaf5c70 elementor-widget elementor-widget-heading\" data-id=\"eaf5c70\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-heading-title elementor-size-default\">79106 Freiburg i. Br.<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-title-color=\"#7A7A7A\" class=\"elementor-element elementor-element-425c6f9f elementor-widget elementor-widget-heading\" data-id=\"425c6f9f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-heading-title elementor-size-default\"><a href=\"tel:+4976127028902\">Tel.: 0761 270-28902 (nur bei Fragen zur pflegerischen Aufnahme)<\/a><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-title-color=\"#7A7A7A\" class=\"elementor-element elementor-element-4a1d6259 elementor-widget elementor-widget-heading\" data-id=\"4a1d6259\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-heading-title elementor-size-default\"><a href=\"mailto:pflegerische-aufnahme-urologie@uniklinik-freiburg.de\">pflegerische-aufnahme-urologie@uniklinik-freiburg.de<\/a><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-5bd594aa e-flex e-con-boxed e-con e-child\" data-id=\"5bd594aa\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3ea1f47b elementor-hidden-mobile dce_masking-none elementor-widget elementor-widget-image\" data-id=\"3ea1f47b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"1000\" height=\"254\" src=\"https:\/\/app.lux-solution.de\/opwb73t\/wp-content\/uploads\/sites\/13\/2024\/12\/universitaetsklinikum-freiburg-urologie-logo.png\" class=\"attachment-large size-large wp-image-5371\" alt=\"Logo der Klinik f\u00fcr Urologie des Universit\u00e4tsklinikums Freiburg\" srcset=\"https:\/\/app.lux-solution.de\/opwb73t\/wp-content\/uploads\/sites\/13\/2024\/12\/universitaetsklinikum-freiburg-urologie-logo.png 1000w, https:\/\/app.lux-solution.de\/opwb73t\/wp-content\/uploads\/sites\/13\/2024\/12\/universitaetsklinikum-freiburg-urologie-logo-300x76.png 300w, https:\/\/app.lux-solution.de\/opwb73t\/wp-content\/uploads\/sites\/13\/2024\/12\/universitaetsklinikum-freiburg-urologie-logo-768x195.png 768w\" sizes=\"(max-width: 1000px) 100vw, 1000px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/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\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-13a24a19 e-flex e-con-boxed e-con e-parent\" data-id=\"13a24a19\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-22a2060 elementor-widget elementor-widget-heading\" data-id=\"22a2060\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Pflegerischer Fragebogen<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-field-description=\"{&quot;fields&quot;:[{&quot;custom_id&quot;:&quot;namebezugsperson&quot;,&quot;position&quot;:&quot;elementor-field-label&quot;,&quot;description&quot;:&quot;Bitte geben Sie uns den Namen einer Bezugsperson (Ehegatte, Freunde) oder eines Angeh\\u00f6rigen (Eltern, Kinder) an, welche(r) im Notfall durch uns verst\\u00e4ndigt werden soll.&quot;,&quot;description_text&quot;:&quot;Bitte geben Sie uns den Namen einer Bezugsperson (Ehegatte, Freunde) oder eines Angeh\\u00f6rigen (Eltern, Kinder) an, welche(r) im Notfall durch uns verst\\u00e4ndigt werden soll.&quot;,&quot;tooltip&quot;:true,&quot;tooltip_position&quot;:&quot;top&quot;},{&quot;custom_id&quot;:&quot;hinterlegtpatientenverfuegung&quot;,&quot;position&quot;:&quot;elementor-field-label&quot;,&quot;description&quot;:&quot;Bitte bringen Sie einen Kopie der Vollmacht zum n\\u00e4chsten Termin mit.&quot;,&quot;description_text&quot;:&quot;Bitte bringen Sie einen Kopie der Vollmacht zum n\\u00e4chsten Termin mit.&quot;,&quot;tooltip&quot;:true,&quot;tooltip_position&quot;:&quot;top&quot;},{&quot;custom_id&quot;:&quot;betreuer&quot;,&quot;position&quot;:&quot;elementor-field-label&quot;,&quot;description&quot;:&quot;Ein gesetzlicher Betreuer ist eine Person, die vom Gericht bestellt wurde, um in rechtlichen oder pers\\u00f6nlichen Angelegenheiten zu unterst\\u00fctzen. Dies ist nicht gleichzusetzen mit Nachbarn oder Freunden, die Ihnen gelegentlich helfen.&quot;,&quot;description_text&quot;:&quot;Ein gesetzlicher Betreuer ist eine Person, die vom Gericht bestellt wurde, um in rechtlichen oder pers\\u00f6nlichen Angelegenheiten zu unterst\\u00fctzen. Dies ist nicht gleichzusetzen mit Nachbarn oder Freunden, die Ihnen gelegentlich helfen.&quot;,&quot;tooltip&quot;:true,&quot;tooltip_position&quot;:&quot;top&quot;},{&quot;custom_id&quot;:&quot;auskunftssperre&quot;,&quot;position&quot;:&quot;elementor-field-label&quot;,&quot;description&quot;:&quot;Bitte beachten Sie, dass nur eine generelle Auskunftssperre m\\u00f6glich ist. Aus organisatorischen Gr\\u00fcnden ist es uns nicht m\\u00f6glich, einzelne Personen davon auszuschlie\\u00dfen.&quot;,&quot;description_text&quot;:&quot;Bitte beachten Sie, dass nur eine generelle Auskunftssperre m\\u00f6glich ist. Aus organisatorischen Gr\\u00fcnden ist es uns nicht m\\u00f6glich, einzelne Personen davon auszuschlie\\u00dfen.&quot;,&quot;tooltip&quot;:true,&quot;tooltip_position&quot;:&quot;top&quot;},{&quot;custom_id&quot;:&quot;support_bewegung&quot;,&quot;position&quot;:&quot;elementor-field-label&quot;,&quot;description&quot;:&quot;Bitte bringen Sie Ihre Hilfsmittel mit.&quot;,&quot;description_text&quot;:&quot;Bitte bringen Sie Ihre Hilfsmittel mit.&quot;,&quot;tooltip&quot;:true,&quot;tooltip_position&quot;:&quot;top&quot;},{&quot;custom_id&quot;:&quot;atmung_cpap&quot;,&quot;position&quot;:&quot;elementor-field-label&quot;,&quot;description&quot;:&quot;CPAP steht f\\u00fcr \\&quot;Continuous Positive Airway Pressure\\&quot; (kontinuierlicher positiver Atemwegsdruck).\\nSie helfen dabei, die Schlafqualit\\u00e4t zu verbessern, tags\\u00fcber Schlafmangel zu verringern und die Risiken, die mit unbehandelter Schlafapnoe verbunden sind, wie zum Beispiel Herz-Kreislauf-Erkrnakungen, zu senken.&quot;,&quot;description_text&quot;:&quot;CPAP steht f\\u00fcr \\&quot;Continuous Positive Airway Pressure\\&quot; (kontinuierlicher positiver Atemwegsdruck).\\nSie helfen dabei, die Schlafqualit\\u00e4t zu verbessern, tags\\u00fcber Schlafmangel zu verringern und die Risiken, die mit unbehandelter Schlafapnoe verbunden sind, wie zum Beispiel Herz-Kreislauf-Erkrnakungen, zu senken.&quot;,&quot;tooltip&quot;:true,&quot;tooltip_position&quot;:&quot;top&quot;},{&quot;custom_id&quot;:&quot;atmung_raucher_menge&quot;,&quot;position&quot;:&quot;elementor-field-label&quot;,&quot;description&quot;:&quot;Bitte bedenken Sie, dass Rauchen die Wundheilung verz\\u00f6gert.&quot;,&quot;description_text&quot;:&quot;Bitte bedenken Sie, dass Rauchen die Wundheilung verz\\u00f6gert.&quot;,&quot;tooltip&quot;:true,&quot;tooltip_position&quot;:&quot;top&quot;},{&quot;custom_id&quot;:&quot;au_auswahl&quot;,&quot;position&quot;:&quot;elementor-field-label&quot;,&quot;description&quot;:&quot;Eine AU erhalten Sie am Tag der Entlassung.&quot;,&quot;description_text&quot;:&quot;Eine AU erhalten Sie am Tag der Entlassung.&quot;,&quot;tooltip&quot;:true,&quot;tooltip_position&quot;:&quot;top&quot;},{&quot;custom_id&quot;:&quot;reha_auswahl&quot;,&quot;position&quot;:&quot;elementor-field-label&quot;,&quot;description&quot;:&quot;Ob eine Reha m\\u00f6glich ist, h\\u00e4ngt von Ihrer Diagnose ab.&quot;,&quot;description_text&quot;:&quot;Ob eine Reha m\\u00f6glich ist, h\\u00e4ngt von Ihrer Diagnose ab.&quot;,&quot;tooltip&quot;:true,&quot;tooltip_position&quot;:&quot;top&quot;}]}\" class=\"elementor-element elementor-element-67a8a968 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"67a8a968\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;N\\u00e4chster&quot;,&quot;step_previous_label&quot;:&quot;Voriger&quot;,&quot;step_type&quot;:&quot;progress_bar&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;label_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;field_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"dce-conditions-js-error-notice elementor-message elementor-message-danger\" style=\"display: none;\">A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.<\/div>\t\t\t<script>\n\t\t\tsetTimeout(function() {\n\t\t\t\tlet el = document.querySelector(\".dce-conditions-js-error-notice\");\n\t\t\t\tif (el)\n\t\t\t\t\tel.style.display = \"block\";\n\t\t\t}, 6000);\n\t\t\t<\/script>\t\t<form class=\"elementor-form\" method=\"post\" name=\"LUX Pflegerische Fragebogen\" aria-label=\"LUX Pflegerische Fragebogen\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"4814\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"67a8a968\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Klinik f\u00fcr Urologie | UKF\" \/>\n\n\t\t\t\n\t\t\t<div data-field-conditions=\"[{&quot;id&quot;:&quot;hinterlegtpatientenverfuegung&quot;,&quot;condition&quot;:&quot;(patientenverfuegung==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;betreuer_text&quot;,&quot;condition&quot;:&quot;(betreuer==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;jaimplantate&quot;,&quot;condition&quot;:&quot;(implantate==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;kontrastmittel&quot;,&quot;condition&quot;:&quot;(allergien==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;desinfektionsmittel&quot;,&quot;condition&quot;:&quot;(allergien==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;pflaster&quot;,&quot;condition&quot;:&quot;(allergien==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;latex&quot;,&quot;condition&quot;:&quot;(allergien==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;medikamente&quot;,&quot;condition&quot;:&quot;(allergien==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;lebensmittel&quot;,&quot;condition&quot;:&quot;(allergien==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;allergiensonstiges&quot;,&quot;condition&quot;:&quot;(allergien==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;field_2d5f15d&quot;,&quot;condition&quot;:&quot;(allergiepass==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;dauermedikation_dosierung&quot;,&quot;condition&quot;:&quot;(dauermedikation==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;field_77a4f8d&quot;,&quot;condition&quot;:&quot;(medikationsplan==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;jainfektionskrankheiten&quot;,&quot;condition&quot;:&quot;(infektionskrankheiten==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;bewegung_schwindel_text&quot;,&quot;condition&quot;:&quot;(bewegung==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;bewegung_gangunsicherheit_text&quot;,&quot;condition&quot;:&quot;(bewegung==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;bewegung_zittern_text&quot;,&quot;condition&quot;:&quot;(bewegung==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;bewegung_sturzereignis_text&quot;,&quot;condition&quot;:&quot;(bewegung==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;bewegung_sonstiges_text&quot;,&quot;condition&quot;:&quot;(bewegung==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;support_bewegung_auswahl&quot;,&quot;condition&quot;:&quot;(support_bewegung==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;support_bewegung_sonstiges_text&quot;,&quot;condition&quot;:&quot;(support_bewegung==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;hautzustand_text&quot;,&quot;condition&quot;:&quot;(hautzustand==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;hautzustand_verbandswechsel&quot;,&quot;condition&quot;:&quot;(hautzustand==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;hautzustand_verbandswechsel_text&quot;,&quot;condition&quot;:&quot;(hautzustand==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;hautzustand_verbandswechsel_angaben&quot;,&quot;condition&quot;:&quot;(hautzustand==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;koerperpflege_text&quot;,&quot;condition&quot;:&quot;(koerperpflege_frage==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;ankleiden_text&quot;,&quot;condition&quot;:&quot;(ankleiden==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;urin_beschwerden_zwar_text&quot;,&quot;condition&quot;:&quot;(urin_beschwerden==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;urin_beschwerden_katheter&quot;,&quot;condition&quot;:&quot;(urin_beschwerden==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;urin_beschwerden_stoma_text&quot;,&quot;condition&quot;:&quot;(urin_beschwerden==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;urin_beschwerden_dialyse_text&quot;,&quot;condition&quot;:&quot;(urin_beschwerden==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;urin_beschwerden_inkontinenz&quot;,&quot;condition&quot;:&quot;(urin_beschwerden==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;urin_beschwerden_hilfsmittel&quot;,&quot;condition&quot;:&quot;(urin_beschwerden==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;urin_unterstuetzung_hilfsmittel&quot;,&quot;condition&quot;:&quot;(urin_unterstuetzung==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;atmung_atemnot&quot;,&quot;condition&quot;:&quot;(atmung==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;atmung_raucher_menge&quot;,&quot;condition&quot;:&quot;(atmung_rauchen_auswahl==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;zahnersatz_zwar&quot;,&quot;condition&quot;:&quot;(zahnersatz==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;kostform_text&quot;,&quot;condition&quot;:&quot;(kostform==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;ernaehrung_unterstuetzung_text&quot;,&quot;condition&quot;:&quot;(ernaehrung_unterstuetzung==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;hilfsmittel_text&quot;,&quot;condition&quot;:&quot;(kommunikation_hilfsmittel==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;hilfsmittel_auswahl&quot;,&quot;condition&quot;:&quot;(kommunikation_hilfsmittel==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;dolmetscher_sprache&quot;,&quot;condition&quot;:&quot;(dolmetscher==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;schmerz_schlafprobleme_text&quot;,&quot;condition&quot;:&quot;(schmerz_schlafprobleme==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;schmerz_schlafprobleme_auswahl&quot;,&quot;condition&quot;:&quot;(schmerz_schlafprobleme==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;schmerzen_schlaftabletten&quot;,&quot;condition&quot;:&quot;(schmerz_schlafprobleme==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;schmerz_schmerzen_zwar&quot;,&quot;condition&quot;:&quot;(schmerz_schmerzen==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;schmerz_schmerzen_auswahl&quot;,&quot;condition&quot;:&quot;(schmerz_schmerzen==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;schmerz_schmerzen_massnahmen&quot;,&quot;condition&quot;:&quot;(schmerz_schmerzen==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;versorgungbekannte&quot;,&quot;condition&quot;:&quot;(versorgung==\\&quot;Ich bekomme Unterst\\u00fctzung durch Angeh\\u00f6rige\\\/Bekannte\\&quot;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;versorgungpflegedienst&quot;,&quot;condition&quot;:&quot;(versorgung==\\&quot;Ich bekomme Unterst\\u00fctzung durch einen ambulanten Pflegedienst\\&quot;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;versorgungpflegeheim&quot;,&quot;condition&quot;:&quot;(versorgung==&#039;Ich lebe in einer Pflegeeinrichtung&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;versorgungwohnen&quot;,&quot;condition&quot;:&quot;(versorgung==&#039;Ich lebe in einer Pflegeeinrichtung&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;versorgungkurzzeitpflege&quot;,&quot;condition&quot;:&quot;(versorgung==&#039;Ich lebe in einer Pflegeeinrichtung&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;koerperpflege&quot;,&quot;condition&quot;:&quot;(versorgung==&#039;Ich lebe in einer Pflegeeinrichtung&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;koerperpflege&quot;,&quot;condition&quot;:&quot;(versorgung==&#039;Ich lebe in einer Pflegeeinrichtung&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;hilfehaushalt&quot;,&quot;condition&quot;:&quot;(versorgung==&#039;Ich lebe in einer Pflegeeinrichtung&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;hilfesonstiges&quot;,&quot;condition&quot;:&quot;(versorgung==&#039;Ich lebe in einer Pflegeeinrichtung&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;abschluss_fluechtling_text&quot;,&quot;condition&quot;:&quot;(versorgung==&#039;Ich lebe in einer Fl\\u00fcchtlingsunterkunft&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;abschluss_obdach_text&quot;,&quot;condition&quot;:&quot;(versorgung==&#039;Ich lebe in einer Obdachlosenunterkunft&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;abschluss_krankenhaus_text&quot;,&quot;condition&quot;:&quot;(abschluss_krankenhaus==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;field_064a1c6&quot;,&quot;condition&quot;:&quot;(send_pdf==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false},{&quot;id&quot;:&quot;email&quot;,&quot;condition&quot;:&quot;(send_pdf==&#039;JA&#039;)&quot;,&quot;mode&quot;:&quot;show&quot;,&quot;disableOnly&quot;:false}]\" data-field-ids=\"[&quot;geschlecht&quot;,&quot;geschlecht&quot;,&quot;field_c7aa1ed&quot;,&quot;field_5eadbf3&quot;,&quot;field_fed73c9&quot;,&quot;vorname&quot;,&quot;name&quot;,&quot;geburtsdatum&quot;,&quot;strasse&quot;,&quot;plz&quot;,&quot;ort&quot;,&quot;koerpergroesse&quot;,&quot;koerpergewicht&quot;,&quot;hausarzt&quot;,&quot;field_0d32095&quot;,&quot;namebezugsperson&quot;,&quot;telefonbezugsperson&quot;,&quot;field_7d8ee75&quot;,&quot;patientenverfuegung&quot;,&quot;hinterlegtpatientenverfuegung&quot;,&quot;betreuer&quot;,&quot;betreuer_text&quot;,&quot;auskunftssperre&quot;,&quot;implantate&quot;,&quot;jaimplantate&quot;,&quot;field_e275ab0&quot;,&quot;allergien&quot;,&quot;kontrastmittel&quot;,&quot;desinfektionsmittel&quot;,&quot;pflaster&quot;,&quot;latex&quot;,&quot;medikamente&quot;,&quot;lebensmittel&quot;,&quot;allergiensonstiges&quot;,&quot;allergiepass&quot;,&quot;field_2d5f15d&quot;,&quot;field_65f4ef0&quot;,&quot;dauermedikation&quot;,&quot;dauermedikation_dosierung&quot;,&quot;medikationsplan&quot;,&quot;field_77a4f8d&quot;,&quot;infektionskrankheiten&quot;,&quot;jainfektionskrankheiten&quot;,&quot;field_201cfd9&quot;,&quot;field_2dd93ab&quot;,&quot;bewegung&quot;,&quot;bewegung_schwindel_text&quot;,&quot;bewegung_gangunsicherheit_text&quot;,&quot;bewegung_zittern_text&quot;,&quot;bewegung_sturzereignis_text&quot;,&quot;bewegung_sonstiges_text&quot;,&quot;field_0af58e9&quot;,&quot;problemlosgehen&quot;,&quot;field_8bbffed&quot;,&quot;support_bewegung&quot;,&quot;support_bewegung_auswahl&quot;,&quot;support_bewegung_sonstiges_text&quot;,&quot;field_201cfd9&quot;,&quot;field_b799206&quot;,&quot;hautzustand&quot;,&quot;hautzustand_text&quot;,&quot;hautzustand_verbandswechsel&quot;,&quot;hautzustand_verbandswechsel_text&quot;,&quot;hautzustand_verbandswechsel_angaben&quot;,&quot;field_2248153&quot;,&quot;thrombose&quot;,&quot;field_134e05e&quot;,&quot;koerperpflege_frage&quot;,&quot;koerperpflege_text&quot;,&quot;field_746635b&quot;,&quot;ankleiden&quot;,&quot;ankleiden_text&quot;,&quot;field_d9f1eed&quot;,&quot;field_abd1c95&quot;,&quot;urin_beschwerden&quot;,&quot;urin_beschwerden_zwar_text&quot;,&quot;urin_beschwerden_katheter&quot;,&quot;urin_beschwerden_stoma_text&quot;,&quot;urin_beschwerden_dialyse_text&quot;,&quot;urin_beschwerden_inkontinenz&quot;,&quot;urin_beschwerden_hilfsmittel&quot;,&quot;field_93c10aa&quot;,&quot;urin_unterstuetzung&quot;,&quot;urin_unterstuetzung_hilfsmittel&quot;,&quot;field_76437be&quot;,&quot;field_f3bb9a0&quot;,&quot;atmung&quot;,&quot;atmung_atemnot&quot;,&quot;field_4fa8b82&quot;,&quot;atmung_cpap&quot;,&quot;field_794a11e&quot;,&quot;atmung_rauchen_auswahl&quot;,&quot;atmung_raucher_menge&quot;,&quot;field_dff778c&quot;,&quot;hilfsmittel&quot;,&quot;zahnersatz&quot;,&quot;zahnersatz_zwar&quot;,&quot;field_f998da5&quot;,&quot;kostform&quot;,&quot;kostform_text&quot;,&quot;field_a828348&quot;,&quot;ernaehrung_unterstuetzung&quot;,&quot;ernaehrung_unterstuetzung_text&quot;,&quot;field_c686d0a&quot;,&quot;field_7f5b3a7&quot;,&quot;kommunikation_hilfsmittel&quot;,&quot;hilfsmittel_text&quot;,&quot;hilfsmittel_auswahl&quot;,&quot;field_0099321&quot;,&quot;dolmetscher&quot;,&quot;dolmetscher_sprache&quot;,&quot;field_e2d2992&quot;,&quot;field_e0d953c&quot;,&quot;schmerz_schlafprobleme&quot;,&quot;schmerz_schlafprobleme_text&quot;,&quot;schmerz_schlafprobleme_auswahl&quot;,&quot;schmerzen_schlaftabletten&quot;,&quot;field_315ed0c&quot;,&quot;schmerz_schmerzen&quot;,&quot;schmerz_schmerzen_zwar&quot;,&quot;schmerz_schmerzen_auswahl&quot;,&quot;schmerz_schmerzen_massnahmen&quot;,&quot;field_053910a&quot;,&quot;field_6b1ee09&quot;,&quot;versorgung&quot;,&quot;versorgungbekannte&quot;,&quot;versorgungpflegedienst&quot;,&quot;versorgungpflegeheim&quot;,&quot;versorgungwohnen&quot;,&quot;versorgungkurzzeitpflege&quot;,&quot;koerperpflege&quot;,&quot;koerperpflege&quot;,&quot;hilfehaushalt&quot;,&quot;hilfesonstiges&quot;,&quot;abschluss_fluechtling_text&quot;,&quot;abschluss_obdach_text&quot;,&quot;field_703617d&quot;,&quot;pflegegrad&quot;,&quot;field_9f6eb77&quot;,&quot;au_auswahl&quot;,&quot;field_133cca3&quot;,&quot;reha_auswahl&quot;,&quot;field_7784cae&quot;,&quot;field_abe6ca5&quot;,&quot;abschluss_krankenhaus&quot;,&quot;abschluss_krankenhaus_text&quot;,&quot;field_6a5a11a&quot;,&quot;beratung&quot;,&quot;beratung_auswahl&quot;,&quot;field_6a5a11a&quot;,&quot;field_064a1c6&quot;,&quot;send_pdf&quot;,&quot;email&quot;,&quot;field_4b8f3a5&quot;,&quot;datenschutz&quot;,&quot;field_d700ff8&quot;,&quot;signature_patient&quot;,&quot;signature_angehoerige&quot;,&quot;datumzeit&quot;,&quot;bmi&quot;]\" class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-geschlecht elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Pers\u00f6nliche Daten\" data-previousButton=\"\" data-nextButton=\"zu den pers\u00f6nlichen Daten\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-geschlecht elementor-col-100\">\n\t\t\t\t\t<style>\n  \/* Verstecke den gesamten Inhalt der Seite standardm\u00e4\u00dfig *\/\n  body {\n    visibility: hidden;\n    opacity: 0;\n    transition: opacity 0.3s ease-in-out; \/* Sanfte \u00dcberblendung *\/\n  }\n<\/style>\n\n<script>\n  document.addEventListener(\"DOMContentLoaded\", function() {\n    \/\/ Zeigt den Inhalt der Seite, nachdem das DOM vollst\u00e4ndig geladen wurde\n    document.body.style.visibility = \"visible\";\n    document.body.style.opacity = \"1\";\n  });\n<\/script>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_c7aa1ed elementor-col-100\">\n\t\t\t\t\t<script>\n    document.addEventListener(\"DOMContentLoaded\", function() {\n        var form = document.querySelector('.elementor-form');\n        if (form) {\n            form.setAttribute('autocomplete', 'off');\n        }\n    });\n<\/script>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5eadbf3 elementor-col-100\">\n\t\t\t\t\t<div style=\"text-align: center;\">\n  <b style=\"font-size: 25px;\">Pflegerischer Fragebogen<\/b><br\/>zur station\u00e4ren Aufnahme Chirurgie<br><br><br\/>\n Sehr geehrte Patientin, sehr geehrter Patient,<br><br>\nf\u00fcr eine optimale medizinisch-pflegerische Versorgung bitten wir Sie die folgenden Fragen zu beantworten.<br>\nWir m\u00f6chten im Voraus \u00fcber Ihren gesundheitlichen Zustand bestens informiert sein.<br>\nDas ausf\u00fchrliche Aufnahmegespr\u00e4ch erfolgt zus\u00e4tzlich an Ihrem ersten Stationstag. <br>\nBitte nehmen Sie sich ausreichend Zeit f\u00fcr das Ausf\u00fcllen Ihres Fragebogens und<br>\nziehen Sie bei Bedarf auch Ihre Angeh\u00f6rigen zu Rate. <br\/><br\/>\nVielen Dank f\u00fcr Ihre Unterst\u00fctzung!<br\/><br\/><br\/>\n<\/div>\n<div style=\"display: flex; justify-content: center; text-align: left;\">\n  <div>\n\n  <\/div>\n<\/div><br\/><br\/>\n\n<style>\n  @media (max-width: 600px) {\n    b[style*=\"font-size: 25px;\"] {\n      font-size: 20px !important;\n    }\n    b[style*=\"background-color: #B62B30;\"] {\n      font-size: 18px !important;\n      padding: 8px !important;\n    }\n    div[style*=\"display: flex;\"] {\n      flex-direction: column !important;\n      align-items: center !important;\n    }\n  }\n<\/style>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_fed73c9 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"*START\" data-previousButton=\"zur\u00fcck\" data-nextButton=\"Aktivit\u00e4t &amp; Bewegung\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-vorname elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-vorname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tVorname\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[vorname]\" id=\"form-field-vorname\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNachname\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-geburtsdatum elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-geburtsdatum\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGeburtsdatum\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[geburtsdatum]\" id=\"form-field-geburtsdatum\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-strasse elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-strasse\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tStra\u00dfe\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[strasse]\" id=\"form-field-strasse\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-plz elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-plz\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPLZ\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[plz]\" id=\"form-field-plz\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-ort elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-ort\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOrt\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[ort]\" id=\"form-field-ort\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-koerpergroesse elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-koerpergroesse\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIhre K\u00f6rpergr\u00f6\u00dfe (in cm)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[koerpergroesse]\" id=\"form-field-koerpergroesse\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-koerpergewicht elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-koerpergewicht\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIhr K\u00f6rpergewicht (in kg)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[koerpergewicht]\" id=\"form-field-koerpergewicht\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-hausarzt elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hausarzt\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIhr Hausarzt\/Praxis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[hausarzt]\" id=\"form-field-hausarzt\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0d32095 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-namebezugsperson elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-namebezugsperson\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName der Bezugsperson\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[namebezugsperson]\" id=\"form-field-namebezugsperson\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-telefonbezugsperson elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-telefonbezugsperson\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTelefonnummer der Bezugsperson (Festnetz\/Mobil)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[telefonbezugsperson]\" id=\"form-field-telefonbezugsperson\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7d8ee75 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-patientenverfuegung elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientenverfuegung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie eine Patientenverf\u00fcgung?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-patientenverfuegung-0\" name=\"form_fields[patientenverfuegung]\"> <label for=\"form-field-patientenverfuegung-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-patientenverfuegung-1\" name=\"form_fields[patientenverfuegung]\"> <label for=\"form-field-patientenverfuegung-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-hinterlegtpatientenverfuegung elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hinterlegtpatientenverfuegung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, diese ist hinterlegt bei: \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[hinterlegtpatientenverfuegung]\" id=\"form-field-hinterlegtpatientenverfuegung\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-betreuer elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-betreuer\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie einen gesetzlichen Betreuer?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-betreuer-0\" name=\"form_fields[betreuer]\"> <label for=\"form-field-betreuer-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-betreuer-1\" name=\"form_fields[betreuer]\"> <label for=\"form-field-betreuer-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-betreuer_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-betreuer_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBitte Namen und Anschrift eintragen\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[betreuer_text]\" id=\"form-field-betreuer_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-auskunftssperre elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-auskunftssperre\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGibt es eine Auskunftssperre?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-auskunftssperre-0\" name=\"form_fields[auskunftssperre]\"> <label for=\"form-field-auskunftssperre-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-auskunftssperre-1\" name=\"form_fields[auskunftssperre]\"> <label for=\"form-field-auskunftssperre-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-implantate elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-implantate\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie Implantate oder implantierte Fremdk\u00f6rper?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-implantate-0\" name=\"form_fields[implantate]\"> <label for=\"form-field-implantate-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-implantate-1\" name=\"form_fields[implantate]\"> <label for=\"form-field-implantate-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-jaimplantate elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-jaimplantate\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, und zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[jaimplantate]\" id=\"form-field-jaimplantate\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_e275ab0 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-allergien elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-allergien\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSind bei Ihnen Allergien bekannt?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-allergien-0\" name=\"form_fields[allergien]\"> <label for=\"form-field-allergien-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-allergien-1\" name=\"form_fields[allergien]\"> <label for=\"form-field-allergien-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-kontrastmittel elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-kontrastmittel\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tKontrastmittel\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-kontrastmittel-0\" name=\"form_fields[kontrastmittel]\"> <label for=\"form-field-kontrastmittel-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-kontrastmittel-1\" name=\"form_fields[kontrastmittel]\"> <label for=\"form-field-kontrastmittel-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-desinfektionsmittel elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-desinfektionsmittel\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tJod\/Desinfektionsmittel\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-desinfektionsmittel-0\" name=\"form_fields[desinfektionsmittel]\"> <label for=\"form-field-desinfektionsmittel-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-desinfektionsmittel-1\" name=\"form_fields[desinfektionsmittel]\"> <label for=\"form-field-desinfektionsmittel-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-pflaster elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-pflaster\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPflaster\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-pflaster-0\" name=\"form_fields[pflaster]\"> <label for=\"form-field-pflaster-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-pflaster-1\" name=\"form_fields[pflaster]\"> <label for=\"form-field-pflaster-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-latex elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-latex\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLatex\/Nickel\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-latex-0\" name=\"form_fields[latex]\"> <label for=\"form-field-latex-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-latex-1\" name=\"form_fields[latex]\"> <label for=\"form-field-latex-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medikamente elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medikamente\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMedikamente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medikamente]\" id=\"form-field-medikamente\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"z.B. Antibiotika\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-lebensmittel elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-lebensmittel\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLebensmittel\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[lebensmittel]\" id=\"form-field-lebensmittel\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"z.B. Fisch, N\u00fcsse etc.\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-allergiensonstiges elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-allergiensonstiges\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSonstiges\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[allergiensonstiges]\" id=\"form-field-allergiensonstiges\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-allergiepass elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-allergiepass\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAllergiepass vorhanden?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-allergiepass-0\" name=\"form_fields[allergiepass]\"> <label for=\"form-field-allergiepass-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-allergiepass-1\" name=\"form_fields[allergiepass]\"> <label for=\"form-field-allergiepass-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2d5f15d elementor-col-100\">\n\t\t\t\t\t<div style=\"background-color: #C00A26; color: white; padding: 20px; text-align: center;\">\n    Bitte bringen Sie den Allergiepass mit.\n<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_65f4ef0 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-dauermedikation elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dauermedikation\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDauermedikation vorhanden?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-dauermedikation-0\" name=\"form_fields[dauermedikation]\"> <label for=\"form-field-dauermedikation-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-dauermedikation-1\" name=\"form_fields[dauermedikation]\"> <label for=\"form-field-dauermedikation-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-dauermedikation_dosierung elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dauermedikation_dosierung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBitte geben Sie alle Medikamente inklusive Dosierung und Einnahmehinweise an.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[dauermedikation_dosierung]\" id=\"form-field-dauermedikation_dosierung\" rows=\"4\" placeholder=\"(Pr\u00e4parat, Dosierung, Verabreichungsform | z.B. Ramipril, 5mg, 1-0-1\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-medikationsplan elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medikationsplan\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMedikationsplan vorhanden?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-medikationsplan-0\" name=\"form_fields[medikationsplan]\"> <label for=\"form-field-medikationsplan-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-medikationsplan-1\" name=\"form_fields[medikationsplan]\"> <label for=\"form-field-medikationsplan-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_77a4f8d elementor-col-100\">\n\t\t\t\t\t<div style=\"background-color: #C00A26; color: white; padding: 20px; text-align: center;\">\n    Bitte bringen Sie die Medikamente f\u00fcr 3 Tage und den QR-Code mit.\n<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-infektionskrankheiten elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-infektionskrankheiten\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSind bei Ihnen Infektionskrankheiten (Hepatitis, HIV...) bekannt?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-infektionskrankheiten-0\" name=\"form_fields[infektionskrankheiten]\"> <label for=\"form-field-infektionskrankheiten-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-infektionskrankheiten-1\" name=\"form_fields[infektionskrankheiten]\"> <label for=\"form-field-infektionskrankheiten-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-jainfektionskrankheiten elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-jainfektionskrankheiten\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, und zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[jainfektionskrankheiten]\" id=\"form-field-jainfektionskrankheiten\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_201cfd9 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"*AKTIVIT\u00c4TEN BEWEGUNG\" data-previousButton=\"zur\u00fcck\" data-nextButton=\"K\u00f6rperpflege &amp; Hautzustand\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2dd93ab elementor-col-100\">\n\t\t\t\t\t<center><b>AKTIVIT\u00c4TEN BEWEGUNG<\/b><\/center>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-bewegung elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-bewegung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie Einschr\u00e4nkungen in der Bewegung?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-bewegung-0\" name=\"form_fields[bewegung]\"> <label for=\"form-field-bewegung-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-bewegung-1\" name=\"form_fields[bewegung]\"> <label for=\"form-field-bewegung-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-bewegung_schwindel_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-bewegung_schwindel_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSchwindel\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[bewegung_schwindel_text]\" id=\"form-field-bewegung_schwindel_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"z.B. \u201eIch habe beim Aufstehen Schwindel\u201c\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-bewegung_gangunsicherheit_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-bewegung_gangunsicherheit_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGangunsicherheit\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[bewegung_gangunsicherheit_text]\" id=\"form-field-bewegung_gangunsicherheit_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"z.B. &quot;Ich f\u00fchle mich unsicher auf unebenem Boden&quot;\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-bewegung_zittern_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-bewegung_zittern_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tZittern\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[bewegung_zittern_text]\" id=\"form-field-bewegung_zittern_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"z.B. \u201eZittern tritt vor allem in den Beinen auf\u201c\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-bewegung_sturzereignis_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-bewegung_sturzereignis_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSturzereignis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[bewegung_sturzereignis_text]\" id=\"form-field-bewegung_sturzereignis_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"z.B. \u201eIch f\u00fchle mich unsicher und stolpere leicht\u201c\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-bewegung_sonstiges_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-bewegung_sonstiges_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSonstiges\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[bewegung_sonstiges_text]\" id=\"form-field-bewegung_sonstiges_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"\u201eMeine Beweglichkeit ist durch eine fr\u00fchere Verletzung eingeschr\u00e4nkt\u201c\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0af58e9 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-problemlosgehen elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-problemlosgehen\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWie weit k\u00f6nnen Sie problemlos gehen?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"weniger als 50m\" id=\"form-field-problemlosgehen-0\" name=\"form_fields[problemlosgehen]\"> <label for=\"form-field-problemlosgehen-0\">weniger als 50m<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"50m\" id=\"form-field-problemlosgehen-1\" name=\"form_fields[problemlosgehen]\"> <label for=\"form-field-problemlosgehen-1\">50m<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"150m\" id=\"form-field-problemlosgehen-2\" name=\"form_fields[problemlosgehen]\"> <label for=\"form-field-problemlosgehen-2\">150m<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"500m\" id=\"form-field-problemlosgehen-3\" name=\"form_fields[problemlosgehen]\"> <label for=\"form-field-problemlosgehen-3\">500m<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"mehr als 500m\" id=\"form-field-problemlosgehen-4\" name=\"form_fields[problemlosgehen]\"> <label for=\"form-field-problemlosgehen-4\">mehr als 500m<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8bbffed elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-support_bewegung elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-support_bewegung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie Hilfsmittel zur Unterst\u00fctzung der Bewegung?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-support_bewegung-0\" name=\"form_fields[support_bewegung]\"> <label for=\"form-field-support_bewegung-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-support_bewegung-1\" name=\"form_fields[support_bewegung]\"> <label for=\"form-field-support_bewegung-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-support_bewegung_auswahl elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Gehstock\/Gehst\u00fctzen\" id=\"form-field-support_bewegung_auswahl-0\" name=\"form_fields[support_bewegung_auswahl][]\"> <label for=\"form-field-support_bewegung_auswahl-0\">Gehstock\/Gehst\u00fctzen<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Rollator\" id=\"form-field-support_bewegung_auswahl-1\" name=\"form_fields[support_bewegung_auswahl][]\"> <label for=\"form-field-support_bewegung_auswahl-1\">Rollator<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Rollstuhl\" id=\"form-field-support_bewegung_auswahl-2\" name=\"form_fields[support_bewegung_auswahl][]\"> <label for=\"form-field-support_bewegung_auswahl-2\">Rollstuhl<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-support_bewegung_sonstiges_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-support_bewegung_sonstiges_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSonstiges (welche?)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[support_bewegung_sonstiges_text]\" id=\"form-field-support_bewegung_sonstiges_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_201cfd9 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"*K\u00d6RPERPFLEGE HAUTZUSTAND\" data-previousButton=\"zur\u00fcck\" data-nextButton=\"URIN &amp; STUHLGANG\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_b799206 elementor-col-100\">\n\t\t\t\t\t<center><b>K\u00d6RPERPFLEGE HAUTZUSTAND<\/b><\/center>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-hautzustand elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hautzustand\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie aktuell Wunden oder Beschwerden mit dem Hautzustand?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-hautzustand-0\" name=\"form_fields[hautzustand]\"> <label for=\"form-field-hautzustand-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-hautzustand-1\" name=\"form_fields[hautzustand]\"> <label for=\"form-field-hautzustand-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-hautzustand_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hautzustand_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tund zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[hautzustand_text]\" id=\"form-field-hautzustand_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-hautzustand_verbandswechsel elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hautzustand_verbandswechsel\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, Verbandswechsel (durch wen? wie oft?)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[hautzustand_verbandswechsel]\" id=\"form-field-hautzustand_verbandswechsel\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\">\n\t\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-hautzustand_verbandswechsel_text elementor-col-80\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[hautzustand_verbandswechsel_text]\" id=\"form-field-hautzustand_verbandswechsel_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-hautzustand_verbandswechsel_angaben elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hautzustand_verbandswechsel_angaben\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tN\u00e4here Angaben\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[hautzustand_verbandswechsel_angaben]\" id=\"form-field-hautzustand_verbandswechsel_angaben\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2248153 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-thrombose elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-thrombose\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHatten Sie oder ein Familienmitglied bereits eine Thrombose?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-thrombose-0\" name=\"form_fields[thrombose]\"> <label for=\"form-field-thrombose-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-thrombose-1\" name=\"form_fields[thrombose]\"> <label for=\"form-field-thrombose-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_134e05e elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-koerperpflege_frage elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-koerperpflege_frage\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBen\u00f6tigen Sie Unterst\u00fctzung bei der K\u00f6rperpflege?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-koerperpflege_frage-0\" name=\"form_fields[koerperpflege_frage]\"> <label for=\"form-field-koerperpflege_frage-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-koerperpflege_frage-1\" name=\"form_fields[koerperpflege_frage]\"> <label for=\"form-field-koerperpflege_frage-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-koerperpflege_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-koerperpflege_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, und zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[koerperpflege_text]\" id=\"form-field-koerperpflege_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_746635b elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-ankleiden elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-ankleiden\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBen\u00f6tigen Sie Unterst\u00fctzung beim Ankleiden?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-ankleiden-0\" name=\"form_fields[ankleiden]\"> <label for=\"form-field-ankleiden-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-ankleiden-1\" name=\"form_fields[ankleiden]\"> <label for=\"form-field-ankleiden-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-ankleiden_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-ankleiden_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, und zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[ankleiden_text]\" id=\"form-field-ankleiden_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_d9f1eed elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"*URIN &amp; STUHLGANG\" data-previousButton=\"zur\u00fcck\" data-nextButton=\"ATMUNG\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_abd1c95 elementor-col-100\">\n\t\t\t\t\t<center><b>URIN & STUHLGANG<\/b><\/center>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-urin_beschwerden elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-urin_beschwerden\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie aktuell Beschwerden\/Auff\u00e4lligkeiten beim Stuhlgang und\/oder beim Wasserlassen?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-urin_beschwerden-0\" name=\"form_fields[urin_beschwerden]\"> <label for=\"form-field-urin_beschwerden-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-urin_beschwerden-1\" name=\"form_fields[urin_beschwerden]\"> <label for=\"form-field-urin_beschwerden-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-urin_beschwerden_zwar_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-urin_beschwerden_zwar_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, und zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[urin_beschwerden_zwar_text]\" id=\"form-field-urin_beschwerden_zwar_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-urin_beschwerden_katheter elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-urin_beschwerden_katheter\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja,Katheter (Versorgung durch?)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[urin_beschwerden_katheter]\" id=\"form-field-urin_beschwerden_katheter\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-urin_beschwerden_stoma_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-urin_beschwerden_stoma_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja,Stoma (Versorgung durch?)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[urin_beschwerden_stoma_text]\" id=\"form-field-urin_beschwerden_stoma_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-urin_beschwerden_dialyse_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-urin_beschwerden_dialyse_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja,regelm\u00e4\u00dfige Dialyse & welche?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[urin_beschwerden_dialyse_text]\" id=\"form-field-urin_beschwerden_dialyse_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-urin_beschwerden_inkontinenz elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-urin_beschwerden_inkontinenz\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLeiden Sie an Inkontinenz?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-urin_beschwerden_inkontinenz-0\" name=\"form_fields[urin_beschwerden_inkontinenz]\"> <label for=\"form-field-urin_beschwerden_inkontinenz-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-urin_beschwerden_inkontinenz-1\" name=\"form_fields[urin_beschwerden_inkontinenz]\"> <label for=\"form-field-urin_beschwerden_inkontinenz-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-urin_beschwerden_hilfsmittel elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-urin_beschwerden_hilfsmittel\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tN\u00e4here Angaben, Hilfsmittel oder pers\u00f6nliche Unterst\u00fctzung\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[urin_beschwerden_hilfsmittel]\" id=\"form-field-urin_beschwerden_hilfsmittel\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_93c10aa elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-urin_unterstuetzung elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-urin_unterstuetzung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBen\u00f6tigen Sie Unterst\u00fctzung bei der Toilettenbenutzung?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-urin_unterstuetzung-0\" name=\"form_fields[urin_unterstuetzung]\"> <label for=\"form-field-urin_unterstuetzung-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-urin_unterstuetzung-1\" name=\"form_fields[urin_unterstuetzung]\"> <label for=\"form-field-urin_unterstuetzung-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-urin_unterstuetzung_hilfsmittel elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-urin_unterstuetzung_hilfsmittel\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHilfsmittel oder pers\u00f6nliche Unterst\u00fctzung\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[urin_unterstuetzung_hilfsmittel]\" id=\"form-field-urin_unterstuetzung_hilfsmittel\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_76437be elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"*ATMUNG\" data-previousButton=\"zur\u00fcck\" data-nextButton=\"FRAGEN ZUR ERN\u00c4HRUNG\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_f3bb9a0 elementor-col-100\">\n\t\t\t\t\t<center><b>ATMUNG<\/b><\/center>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-atmung elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-atmung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie aktuell Beschwerden mit der Atmung? Ben\u00f6tigen Sie Unterst\u00fctzung?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-atmung-0\" name=\"form_fields[atmung]\"> <label for=\"form-field-atmung-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-atmung-1\" name=\"form_fields[atmung]\"> <label for=\"form-field-atmung-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-atmung_atemnot elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Atemnot\" id=\"form-field-atmung_atemnot-0\" name=\"form_fields[atmung_atemnot][]\"> <label for=\"form-field-atmung_atemnot-0\">Atemnot<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Husten\" id=\"form-field-atmung_atemnot-1\" name=\"form_fields[atmung_atemnot][]\"> <label for=\"form-field-atmung_atemnot-1\">Husten<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"COPD\" id=\"form-field-atmung_atemnot-2\" name=\"form_fields[atmung_atemnot][]\"> <label for=\"form-field-atmung_atemnot-2\">COPD<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Asthma\" id=\"form-field-atmung_atemnot-3\" name=\"form_fields[atmung_atemnot][]\"> <label for=\"form-field-atmung_atemnot-3\">Asthma<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Tracheostoma\" id=\"form-field-atmung_atemnot-4\" name=\"form_fields[atmung_atemnot][]\"> <label for=\"form-field-atmung_atemnot-4\">Tracheostoma<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Trachealkan\u00fcle\" id=\"form-field-atmung_atemnot-5\" name=\"form_fields[atmung_atemnot][]\"> <label for=\"form-field-atmung_atemnot-5\">Trachealkan\u00fcle<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heimsauerstoff\" id=\"form-field-atmung_atemnot-6\" name=\"form_fields[atmung_atemnot][]\"> <label for=\"form-field-atmung_atemnot-6\">Heimsauerstoff<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_4fa8b82 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-atmung_cpap elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-atmung_cpap\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCPAP (bitte mitbringen)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-atmung_cpap-0\" name=\"form_fields[atmung_cpap]\"> <label for=\"form-field-atmung_cpap-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-atmung_cpap-1\" name=\"form_fields[atmung_cpap]\"> <label for=\"form-field-atmung_cpap-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_794a11e elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-atmung_rauchen_auswahl elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-atmung_rauchen_auswahl\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRauchen Sie?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-atmung_rauchen_auswahl-0\" name=\"form_fields[atmung_rauchen_auswahl]\"> <label for=\"form-field-atmung_rauchen_auswahl-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-atmung_rauchen_auswahl-1\" name=\"form_fields[atmung_rauchen_auswahl]\"> <label for=\"form-field-atmung_rauchen_auswahl-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-atmung_raucher_menge elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-atmung_raucher_menge\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWie viel pro Tag?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[atmung_raucher_menge]\" id=\"form-field-atmung_raucher_menge\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_dff778c elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"*ERN\u00c4HRUNG\" data-previousButton=\"zur\u00fcck\" data-nextButton=\"KOMMUNIKATION &amp; WAHRNEHMUNG\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-hilfsmittel elementor-col-100\">\n\t\t\t\t\t<center><b>ERN\u00c4HRUNG<\/b><\/center>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-zahnersatz elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-zahnersatz\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie Zahnersatz?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-zahnersatz-0\" name=\"form_fields[zahnersatz]\"> <label for=\"form-field-zahnersatz-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-zahnersatz-1\" name=\"form_fields[zahnersatz]\"> <label for=\"form-field-zahnersatz-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-zahnersatz_zwar elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-zahnersatz_zwar\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, und zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[zahnersatz_zwar]\" id=\"form-field-zahnersatz_zwar\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_f998da5 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-kostform elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-kostform\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBen\u00f6tigen Sie eine besondere Kostform?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-kostform-0\" name=\"form_fields[kostform]\"> <label for=\"form-field-kostform-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-kostform-1\" name=\"form_fields[kostform]\"> <label for=\"form-field-kostform-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-kostform_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-kostform_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, und zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[kostform_text]\" id=\"form-field-kostform_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a828348 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-ernaehrung_unterstuetzung elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-ernaehrung_unterstuetzung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBen\u00f6tigen Sie Unterst\u00fctzung bei der Ern\u00e4hrung?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-ernaehrung_unterstuetzung-0\" name=\"form_fields[ernaehrung_unterstuetzung]\"> <label for=\"form-field-ernaehrung_unterstuetzung-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-ernaehrung_unterstuetzung-1\" name=\"form_fields[ernaehrung_unterstuetzung]\"> <label for=\"form-field-ernaehrung_unterstuetzung-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-ernaehrung_unterstuetzung_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-ernaehrung_unterstuetzung_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tN\u00e4here Angaben\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[ernaehrung_unterstuetzung_text]\" id=\"form-field-ernaehrung_unterstuetzung_text\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_c686d0a elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"*KOMMUNIKATION &amp; WAHRNEHMUNG\" data-previousButton=\"zur\u00fcck\" data-nextButton=\"SCHMERZEN &amp; WOHLBEFINDEN\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7f5b3a7 elementor-col-100\">\n\t\t\t\t\t<center><b>KOMMUNIKATION & WAHRNEHMUNG<\/b><\/center>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-kommunikation_hilfsmittel elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-kommunikation_hilfsmittel\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBen\u00f6tigen Sie Hilfsmittel f\u00fcr die Kommunikation?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-kommunikation_hilfsmittel-0\" name=\"form_fields[kommunikation_hilfsmittel]\"> <label for=\"form-field-kommunikation_hilfsmittel-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-kommunikation_hilfsmittel-1\" name=\"form_fields[kommunikation_hilfsmittel]\"> <label for=\"form-field-kommunikation_hilfsmittel-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-hilfsmittel_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hilfsmittel_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, und zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[hilfsmittel_text]\" id=\"form-field-hilfsmittel_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-hilfsmittel_auswahl elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Brille\" id=\"form-field-hilfsmittel_auswahl-0\" name=\"form_fields[hilfsmittel_auswahl][]\"> <label for=\"form-field-hilfsmittel_auswahl-0\">Brille<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"H\u00f6rger\u00e4t rechts\" id=\"form-field-hilfsmittel_auswahl-1\" name=\"form_fields[hilfsmittel_auswahl][]\"> <label for=\"form-field-hilfsmittel_auswahl-1\">H\u00f6rger\u00e4t rechts<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"H\u00f6rger\u00e4t links\" id=\"form-field-hilfsmittel_auswahl-2\" name=\"form_fields[hilfsmittel_auswahl][]\"> <label for=\"form-field-hilfsmittel_auswahl-2\">H\u00f6rger\u00e4t links<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0099321 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-dolmetscher elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dolmetscher\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBen\u00f6tigen Sie einen Dolmetscher?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-dolmetscher-0\" name=\"form_fields[dolmetscher]\"> <label for=\"form-field-dolmetscher-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-dolmetscher-1\" name=\"form_fields[dolmetscher]\"> <label for=\"form-field-dolmetscher-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-dolmetscher_sprache elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dolmetscher_sprache\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tf\u00fcr welche Sprache?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[dolmetscher_sprache]\" id=\"form-field-dolmetscher_sprache\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_e2d2992 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"*SCHMERZ &amp; WOHLBEFINDEN\" data-previousButton=\"zur\u00fcck\" data-nextButton=\"VERSORGUNG\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_e0d953c elementor-col-100\">\n\t\t\t\t\t<center><b>SCHMERZEN & WOHLBEFINDEN<\/b><\/center>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-schmerz_schlafprobleme elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-schmerz_schlafprobleme\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie Schlafprobleme?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-schmerz_schlafprobleme-0\" name=\"form_fields[schmerz_schlafprobleme]\"> <label for=\"form-field-schmerz_schlafprobleme-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-schmerz_schlafprobleme-1\" name=\"form_fields[schmerz_schlafprobleme]\"> <label for=\"form-field-schmerz_schlafprobleme-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-schmerz_schlafprobleme_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-schmerz_schlafprobleme_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, und zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[schmerz_schlafprobleme_text]\" id=\"form-field-schmerz_schlafprobleme_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-schmerz_schlafprobleme_auswahl elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Einschlafen\" id=\"form-field-schmerz_schlafprobleme_auswahl-0\" name=\"form_fields[schmerz_schlafprobleme_auswahl][]\"> <label for=\"form-field-schmerz_schlafprobleme_auswahl-0\">Einschlafen<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Durchschlafen\" id=\"form-field-schmerz_schlafprobleme_auswahl-1\" name=\"form_fields[schmerz_schlafprobleme_auswahl][]\"> <label for=\"form-field-schmerz_schlafprobleme_auswahl-1\">Durchschlafen<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-schmerzen_schlaftabletten elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-schmerzen_schlaftabletten\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNehmen Sie Schlaftabletten?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-schmerzen_schlaftabletten-0\" name=\"form_fields[schmerzen_schlaftabletten]\"> <label for=\"form-field-schmerzen_schlaftabletten-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-schmerzen_schlaftabletten-1\" name=\"form_fields[schmerzen_schlaftabletten]\"> <label for=\"form-field-schmerzen_schlaftabletten-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_315ed0c elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-schmerz_schmerzen elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-schmerz_schmerzen\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie aktuell Schmerzen?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-schmerz_schmerzen-0\" name=\"form_fields[schmerz_schmerzen]\"> <label for=\"form-field-schmerz_schmerzen-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-schmerz_schmerzen-1\" name=\"form_fields[schmerz_schmerzen]\"> <label for=\"form-field-schmerz_schmerzen-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-schmerz_schmerzen_zwar elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-schmerz_schmerzen_zwar\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, und zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[schmerz_schmerzen_zwar]\" id=\"form-field-schmerz_schmerzen_zwar\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-schmerz_schmerzen_auswahl elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"akut\" id=\"form-field-schmerz_schmerzen_auswahl-0\" name=\"form_fields[schmerz_schmerzen_auswahl][]\"> <label for=\"form-field-schmerz_schmerzen_auswahl-0\">akut<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"chronisch (l\u00e4nger als 3 Monate)\" id=\"form-field-schmerz_schmerzen_auswahl-1\" name=\"form_fields[schmerz_schmerzen_auswahl][]\"> <label for=\"form-field-schmerz_schmerzen_auswahl-1\">chronisch (l\u00e4nger als 3 Monate)<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-schmerz_schmerzen_massnahmen elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-schmerz_schmerzen_massnahmen\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWelche Ma\u00dfnahmen unternehmen Sie?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[schmerz_schmerzen_massnahmen]\" id=\"form-field-schmerz_schmerzen_massnahmen\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_053910a elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"*VERSORGUNG\" data-previousButton=\"zur\u00fcck\" data-nextButton=\"Letzte Fragen\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6b1ee09 elementor-col-100\">\n\t\t\t\t\t<center><b>VERSORGUNG<\/b><\/center>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-versorgung elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-versorgung\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tVersorgen Sie sich zu Hause selbst oder bekommen Sie Unterst\u00fctzung?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Ich versorge mich selbst\" id=\"form-field-versorgung-0\" name=\"form_fields[versorgung]\"> <label for=\"form-field-versorgung-0\">Ich versorge mich selbst<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Ich bekomme Unterst\u00fctzung durch Angeh\u00f6rige\/Bekannte\" id=\"form-field-versorgung-1\" name=\"form_fields[versorgung]\"> <label for=\"form-field-versorgung-1\">Ich bekomme Unterst\u00fctzung durch Angeh\u00f6rige\/Bekannte<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Ich bekomme Unterst\u00fctzung durch einen ambulanten Pflegedienst\" id=\"form-field-versorgung-2\" name=\"form_fields[versorgung]\"> <label for=\"form-field-versorgung-2\">Ich bekomme Unterst\u00fctzung durch einen ambulanten Pflegedienst<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Ich lebe in einer Pflegeeinrichtung\" id=\"form-field-versorgung-3\" name=\"form_fields[versorgung]\"> <label for=\"form-field-versorgung-3\">Ich lebe in einer Pflegeeinrichtung<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Ich lebe in einer Fl\u00fcchtlingsunterkunft\" id=\"form-field-versorgung-4\" name=\"form_fields[versorgung]\"> <label for=\"form-field-versorgung-4\">Ich lebe in einer Fl\u00fcchtlingsunterkunft<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Ich lebe in einer Obdachlosenunterkunft\" id=\"form-field-versorgung-5\" name=\"form_fields[versorgung]\"> <label for=\"form-field-versorgung-5\">Ich lebe in einer Obdachlosenunterkunft<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-versorgungbekannte elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-versorgungbekannte\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, durch wen?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[versorgungbekannte]\" id=\"form-field-versorgungbekannte\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Name und Tel.-Nr.\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-versorgungpflegedienst elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-versorgungpflegedienst\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, welchen\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[versorgungpflegedienst]\" id=\"form-field-versorgungpflegedienst\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Name und Tel.-Nr.\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-versorgungpflegeheim elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-versorgungpflegeheim\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIm Pflegeheim\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[versorgungpflegeheim]\" id=\"form-field-versorgungpflegeheim\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Name und Tel.-Nr.\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-versorgungwohnen elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-versorgungwohnen\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIm betreuten Wohnen\/Seniorenwohnanlage\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[versorgungwohnen]\" id=\"form-field-versorgungwohnen\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Name und Tel.-Nr.\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-versorgungkurzzeitpflege elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-versorgungkurzzeitpflege\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIn Kurzzeitpflege\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[versorgungkurzzeitpflege]\" id=\"form-field-versorgungkurzzeitpflege\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Name und Tel.-Nr.\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-koerperpflege elementor-col-100\">\n\t\t\t\t\tWelche Unterst\u00fctzung erhalten Sie?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-koerperpflege elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-koerperpflege\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tUnterst\u00fctzung bei der K\u00f6rperpflege\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-koerperpflege-0\" name=\"form_fields[koerperpflege]\"> <label for=\"form-field-koerperpflege-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-koerperpflege-1\" name=\"form_fields[koerperpflege]\"> <label for=\"form-field-koerperpflege-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-hilfehaushalt elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hilfehaushalt\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHilfe im Haushalt\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-hilfehaushalt-0\" name=\"form_fields[hilfehaushalt]\"> <label for=\"form-field-hilfehaushalt-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-hilfehaushalt-1\" name=\"form_fields[hilfehaushalt]\"> <label for=\"form-field-hilfehaushalt-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-hilfesonstiges elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hilfesonstiges\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSonstiges\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[hilfesonstiges]\" id=\"form-field-hilfesonstiges\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-abschluss_fluechtling_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-abschluss_fluechtling_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBitte Anschrift eingeben:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[abschluss_fluechtling_text]\" id=\"form-field-abschluss_fluechtling_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-abschluss_obdach_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-abschluss_obdach_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBitte Anschrift eingeben:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[abschluss_obdach_text]\" id=\"form-field-abschluss_obdach_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_703617d elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-pflegegrad elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-pflegegrad\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaben Sie einen Pflegegrad?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"nein\" id=\"form-field-pflegegrad-0\" name=\"form_fields[pflegegrad]\"> <label for=\"form-field-pflegegrad-0\">nein<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"1\" id=\"form-field-pflegegrad-1\" name=\"form_fields[pflegegrad]\"> <label for=\"form-field-pflegegrad-1\">1<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"2\" id=\"form-field-pflegegrad-2\" name=\"form_fields[pflegegrad]\"> <label for=\"form-field-pflegegrad-2\">2<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"3\" id=\"form-field-pflegegrad-3\" name=\"form_fields[pflegegrad]\"> <label for=\"form-field-pflegegrad-3\">3<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"4\" id=\"form-field-pflegegrad-4\" name=\"form_fields[pflegegrad]\"> <label for=\"form-field-pflegegrad-4\">4<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"5\" id=\"form-field-pflegegrad-5\" name=\"form_fields[pflegegrad]\"> <label for=\"form-field-pflegegrad-5\">5<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_9f6eb77 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-au_auswahl elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-au_auswahl\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBen\u00f6tigen Sie eine Arbeitsunf\u00e4higkeitsbescheinigung\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-au_auswahl-0\" name=\"form_fields[au_auswahl]\"> <label for=\"form-field-au_auswahl-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-au_auswahl-1\" name=\"form_fields[au_auswahl]\"> <label for=\"form-field-au_auswahl-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_133cca3 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-reha_auswahl elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-reha_auswahl\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBen\u00f6tigen Sie eine Reha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-reha_auswahl-0\" name=\"form_fields[reha_auswahl]\"> <label for=\"form-field-reha_auswahl-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-reha_auswahl-1\" name=\"form_fields[reha_auswahl]\"> <label for=\"form-field-reha_auswahl-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_7784cae elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"*ABSCHLUSS\" data-previousButton=\"zur\u00fcck\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_abe6ca5 elementor-col-100\">\n\t\t\t\t\t<center><b>ABSCHLUSS<\/b><\/center>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-abschluss_krankenhaus elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-abschluss_krankenhaus\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWaren Sie das letzte Jahr im Krankenhaus?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-abschluss_krankenhaus-0\" name=\"form_fields[abschluss_krankenhaus]\"> <label for=\"form-field-abschluss_krankenhaus-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-abschluss_krankenhaus-1\" name=\"form_fields[abschluss_krankenhaus]\"> <label for=\"form-field-abschluss_krankenhaus-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-abschluss_krankenhaus_text elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-abschluss_krankenhaus_text\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, und zwar:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[abschluss_krankenhaus_text]\" id=\"form-field-abschluss_krankenhaus_text\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6a5a11a elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-beratung elementor-col-100\">\n\t\t\t\t\tBen\u00f6tigen Sie Beratung f\u00fcr eines der folgenden Angebote?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-beratung_auswahl elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-beratung_auswahl\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tja, ich ben\u00f6tige...\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Unterlagen zu Selbsthilfegruppen\" id=\"form-field-beratung_auswahl-0\" name=\"form_fields[beratung_auswahl][]\"> <label for=\"form-field-beratung_auswahl-0\">Unterlagen zu Selbsthilfegruppen<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Beratung in rechtlichen \/ finanziellen Fragen\" id=\"form-field-beratung_auswahl-1\" name=\"form_fields[beratung_auswahl][]\"> <label for=\"form-field-beratung_auswahl-1\">Beratung in rechtlichen \/ finanziellen Fragen<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"psychologische Beratung \/ Begleitung\" id=\"form-field-beratung_auswahl-2\" name=\"form_fields[beratung_auswahl][]\"> <label for=\"form-field-beratung_auswahl-2\">psychologische Beratung \/ Begleitung<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hilfsmittel (Rollstuhl \/ Rollator)\" id=\"form-field-beratung_auswahl-3\" name=\"form_fields[beratung_auswahl][]\"> <label for=\"form-field-beratung_auswahl-3\">Hilfsmittel (Rollstuhl \/ Rollator)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Rehabilitation \/ Anschlussheilbehandlung\" id=\"form-field-beratung_auswahl-4\" name=\"form_fields[beratung_auswahl][]\"> <label for=\"form-field-beratung_auswahl-4\">Rehabilitation \/ Anschlussheilbehandlung<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Familienhilfe\" id=\"form-field-beratung_auswahl-5\" name=\"form_fields[beratung_auswahl][]\"> <label for=\"form-field-beratung_auswahl-5\">Familienhilfe<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Unterst\u00fctzung durch amb. Pflegedienst\" id=\"form-field-beratung_auswahl-6\" name=\"form_fields[beratung_auswahl][]\"> <label for=\"form-field-beratung_auswahl-6\">Unterst\u00fctzung durch amb. Pflegedienst<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hausnotruf\" id=\"form-field-beratung_auswahl-7\" name=\"form_fields[beratung_auswahl][]\"> <label for=\"form-field-beratung_auswahl-7\">Hausnotruf<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Einstufung in eine Pflegestufe\" id=\"form-field-beratung_auswahl-8\" name=\"form_fields[beratung_auswahl][]\"> <label for=\"form-field-beratung_auswahl-8\">Einstufung in eine Pflegestufe<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Mahlzeitendienst\" id=\"form-field-beratung_auswahl-9\" name=\"form_fields[beratung_auswahl][]\"> <label for=\"form-field-beratung_auswahl-9\">Mahlzeitendienst<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6a5a11a elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_064a1c6 elementor-col-100\">\n\t\t\t\t\t<div style=\"background-color: #C00A26; color: white; padding: 20px; text-align: center;\">\n<strong>WICHTIGER HINWEIS<\/strong><br>\nDer Versand von E-Mails erfolgt unverschl\u00fcsselt und birgt Risiken f\u00fcr die Sicherheit Ihrer pers\u00f6nlichen Daten.<br>\nMit dem Absenden des Formulars erkl\u00e4ren Sie sich einverstanden, dass das Universit\u00e4tsklinikum Freiburg<br>\nkeine Haftung f\u00fcr m\u00f6gliche Sicherheitsrisiken \u00fcbernimmt und der Versand auf Ihr eigenes Risiko erfolgt.\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-send_pdf elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-send_pdf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tM\u00f6chten Sie eine PDF-Kopie des Fragebogens an Ihre E-Mail-Adresse geschickt bekommen?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"NEIN\" id=\"form-field-send_pdf-0\" name=\"form_fields[send_pdf]\" required=\"required\"> <label for=\"form-field-send_pdf-0\">NEIN<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-send_pdf-1\" name=\"form_fields[send_pdf]\" required=\"required\"> <label for=\"form-field-send_pdf-1\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBitte geben Sie Ihre E-Mail Adresse ein:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_4b8f3a5 elementor-col-100\">\n\t\t\t\t\t<hr>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-datenschutz elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-datenschutz\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDatenschutz\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"JA\" id=\"form-field-datenschutz-0\" name=\"form_fields[datenschutz]\" required=\"required\"> <label for=\"form-field-datenschutz-0\">JA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_d700ff8 elementor-col-80\">\n\t\t\t\t\tIch stimme zu, dass meine Angaben aus dem Fragebogen erhoben und verarbeitet werden. Die Daten werden nur kurz auf unserem Server zum Versand gespeichert und danach gel\u00f6scht. Sie k\u00f6nnen Ihre Einwilligung jederzeit per E-Mail an pflegerische-aufnahme-urologie@uniklinik-freiburg.de widerrufen. Detaillierte Informationen zum Umgang mit Nutzerdaten finden Sie in unserer Datenschutzerkl\u00e4rung.\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-dce_form_signature elementor-field-group elementor-column elementor-field-group-signature_patient elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-signature_patient\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tUnterschrift der\/des Patient*in\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div style=\"width: 100%; display: block;\">\n\t\t\t<div class=\"dce-signature-wrapper\" style=\"width: var(--canvas-width); min-width: 200px;\">\n\t\t\t\t<div style=\"position: relative; display: inline-block; width: 100%;\">\n\t\t\t\t\t<button type=\"button\"\n\t\t\t\t\t\t\tclass=\"dce-signature-button-clear\"\n\t\t\t\t\t\t\tdata-action=\"clear\"\n\t\t\t\t\t\t\tstyle=\"position: absolute; top: 0; right: 0; z-index: 10;\">\n\t\t\t\t\t\t<svg class=\"e-font-icon-svg e-eicon-close\" viewBox=\"0 0 1000 1000\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M742 167L500 408 258 167C246 154 233 150 217 150 196 150 179 158 167 167 154 179 150 196 150 212 150 229 154 242 171 254L408 500 167 742C138 771 138 800 167 829 196 858 225 858 254 829L496 587 738 829C750 842 767 846 783 846 800 846 817 842 829 829 842 817 846 804 846 783 846 767 842 750 829 737L588 500 833 258C863 229 863 200 833 171 804 137 775 137 742 167Z\"><\/path><\/svg>\t\t\t\t\t<\/button>\n\t\t\t\t\t<input type=\"dce_form_signature\" name=\"form_fields[signature_patient]\" id=\"form-field-signature_patient\" class=\"elementor-field elementor-size-sm \" style=\"width: 0; height: 0; opacity: 0; position: absolute; pointer-events: none;\">\n\t\t\t\t\t<canvas class=\"dce-signature-canvas\" data-pen-color=\"#000000\" data-background-color=\"#ffffff\" data-jpeg=\"no\" data-aspect-ratio=\"2\" width=\"1\" height=\"1\" style=\"width: 100%; height: calc(100% \/ 2); border-style: solid; touch-action: none; user-select: none;\"><\/canvas>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-dce_form_signature elementor-field-group elementor-column elementor-field-group-signature_angehoerige elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-signature_angehoerige\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\toder des Angeh\u00f6rigen\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div style=\"width: 100%; display: block;\">\n\t\t\t<div class=\"dce-signature-wrapper\" style=\"width: var(--canvas-width); min-width: 200px;\">\n\t\t\t\t<div style=\"position: relative; display: inline-block; width: 100%;\">\n\t\t\t\t\t<button type=\"button\"\n\t\t\t\t\t\t\tclass=\"dce-signature-button-clear\"\n\t\t\t\t\t\t\tdata-action=\"clear\"\n\t\t\t\t\t\t\tstyle=\"position: absolute; top: 0; right: 0; z-index: 10;\">\n\t\t\t\t\t\t<svg class=\"e-font-icon-svg e-eicon-close\" viewBox=\"0 0 1000 1000\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M742 167L500 408 258 167C246 154 233 150 217 150 196 150 179 158 167 167 154 179 150 196 150 212 150 229 154 242 171 254L408 500 167 742C138 771 138 800 167 829 196 858 225 858 254 829L496 587 738 829C750 842 767 846 783 846 800 846 817 842 829 829 842 817 846 804 846 783 846 767 842 750 829 737L588 500 833 258C863 229 863 200 833 171 804 137 775 137 742 167Z\"><\/path><\/svg>\t\t\t\t\t<\/button>\n\t\t\t\t\t<input type=\"dce_form_signature\" name=\"form_fields[signature_angehoerige]\" id=\"form-field-signature_angehoerige\" class=\"elementor-field elementor-size-sm \" style=\"width: 0; height: 0; opacity: 0; position: absolute; pointer-events: none;\">\n\t\t\t\t\t<canvas class=\"dce-signature-canvas\" data-pen-color=\"#000000\" data-background-color=\"#ffffff\" data-jpeg=\"no\" data-aspect-ratio=\"2\" width=\"1\" height=\"1\" style=\"width: 100%; height: calc(100% \/ 2); border-style: solid; touch-action: none; user-select: none;\"><\/canvas>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-hidden elementor-field-group elementor-column elementor-field-group-datumzeit elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"hidden\" name=\"form_fields[datumzeit]\" id=\"form-field-datumzeit\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" value=\"10\/05\/2026 18:05\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-amount elementor-field-group elementor-column elementor-field-group-bmi elementor-col-100\">\n\t\t\t\t\t<input type=\"hidden\" name=\"form_fields[bmi]\" id=\"form-field-bmi\" class=\"elementor-field elementor-size-sm  dce-amount-hidden\" data-hide=\"yes\" data-field-expression=\" getField(&quot;gewicht&quot;)  \/ (( getField(&quot;groesse&quot;)  \/ 100) * ( getField(&quot;groesse&quot;)  \/ 100))\" data-text-before=\"\" data-text-after=\"\" data-should-round=\"yes\" data-round-precision=\"1\" data-refresh-on=\"input\" data-should-format=\"\" data-format-precision=\"\" style=\"display: none;\"><input size=\"1\"type=\"text\" class=\"dce-amount-visible elementor-field-textual\" readonly=\"\">\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Senden<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t<style>.elementor-element.elementor-element-67a8a968 .elementor-field-group { align-self: flex-start; }<\/style>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-87e3415 e-flex e-con-boxed e-con e-parent\" data-id=\"87e3415\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-27ed6bc elementor-widget elementor-widget-shortcode\" data-id=\"27ed6bc\" 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\">\t\t<div data-elementor-type=\"container\" data-elementor-id=\"786\" class=\"elementor elementor-786\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t<div class=\"elementor-element elementor-element-329d47f1 e-flex e-con-boxed e-con e-parent\" data-id=\"329d47f1\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-642dbe9 elementor-icon-list--layout-inline elementor-align-center elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"642dbe9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items elementor-inline-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item elementor-inline-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.uniklinik-freiburg.de\/footernavigation\/impressum.html\" target=\"_blank\">\n\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Impressum<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item elementor-inline-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.uniklinik-freiburg.de\/footernavigation\/datenschutz.html\" target=\"_blank\">\n\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Datenschutz<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-title-color=\"#7A7A7A\" class=\"elementor-element elementor-element-39528007 elementor-widget elementor-widget-heading\" data-id=\"39528007\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\"><a href=\"https:\/\/lux-digitalepraxis.de\" target=\"_blank\">\u00a9 2026 LUX Digitale Praxis<\/a><\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/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\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Pflegerischer Fragebogen<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-4814","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/app.lux-solution.de\/opwb73t\/wp-json\/wp\/v2\/pages\/4814","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/app.lux-solution.de\/opwb73t\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/app.lux-solution.de\/opwb73t\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/app.lux-solution.de\/opwb73t\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/app.lux-solution.de\/opwb73t\/wp-json\/wp\/v2\/comments?post=4814"}],"version-history":[{"count":736,"href":"https:\/\/app.lux-solution.de\/opwb73t\/wp-json\/wp\/v2\/pages\/4814\/revisions"}],"predecessor-version":[{"id":6728,"href":"https:\/\/app.lux-solution.de\/opwb73t\/wp-json\/wp\/v2\/pages\/4814\/revisions\/6728"}],"wp:attachment":[{"href":"https:\/\/app.lux-solution.de\/opwb73t\/wp-json\/wp\/v2\/media?parent=4814"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}