Date
|
Name
|
Birthdate
|
Sex
|
Address
|
Legal Representative Name
|
Legal Representative Address
|
Type of Legal Oversight
GuardianConservatorDPOA HealthDPOA Financial
|
|
Contact1 Name
|
Contact1 Relationship
|
Contact1 Address
|
Contact1 Phone
|
Contact2 Name
|
Contact2 Address
|
Contact2 Relationship
|
Contact2 Phone
|
CURRENT LIVING SITUATION
|
WHY IS ADMISSION NEEDED/DESIRED
|
IS THE PROSPECTIVE RESIDENT AWARE OF THIS APPLICATION?
Yes No
|
|
REFERRING PHYSICIAN Name
|
REFERRING PHYSICIAN Address
|
REFERRING PHYSICIAN Phone
|
LAST CHEST XRAY Date
|
LAST CHEST XRAY Location
|
HAS THE APPLICANT EVER TESTED POSITIVE FOR TB?
YesNo |
LAST HOSPITALIZATION Date
|
LAST HOSPITALIZATION Location
|
LAST HOSPITALIZATION Reason
|
PREVIOUS NURSING HOME Name
|
PREVIOUS NURSING HOME Location
|
PREVIOUS NURSING HOME Dates
|
MEDICAL CONDITIONS/DIAGNOSES
|
CURRENT MEDICATIONS
|
ANY CURRENT EVIDENCE OF:
DEPRESSION
CONFUSION
HALLUCINATIONS
PARANOIA
AGITATION
DEMENTIA
MENTAL ILLNESS
SUBSTANCE ABUSE
|
BEHAVIOR PROBLEMS
|
ALCOHOL/DRUG/TOBACCO
|
DIET RESTRICTIONS
|
ALLERGIES/DRUG REACTIONS
|
SKIN PROBLEMS
|
OXYGEN USE
|
ASSISTIVE DEVICES USED:
GLASSES
HEARING AIDS - BOTH EARS
HEARING AIDS - LEFT
HEARING AIDS - RIGHT
DENTURES - FULL
DENTURES - PARTIAL
DENTURES - UPPER
DENTURES - LOWER
WALKER
CANE
WHEELCHAIR
|
ADDITIONAL INFORMATION
|
|
WHAT ASSISTANCE IS NEEDED FOR:
|
EATING:
INDEPENDENT - ABLE TO FEED SELF
MINIMUM - CONGREGATE MEALS, HOME DELIVERED
MODERATE - SET UP OF PLATE, OPENING OF ITEMS, CUTTING
MAXIMUM - SUPERVISION, CUEING NEEDED
TOTAL ASSISTANCE - DEPENDS ON OTHERS TO BE FED |
BATHING:
INDEPENDENT - BATHES/SHOWERS SELF
MINIMUM - REQUIRES BATHING ITEMS SET UP
MODERATE - NEEDS PHYSICAL ASSISTANCE IN & OUT OF BATH
MAXIMUM - NEEDS PARTIAL “HANDS ON” ASSISTANCE
TOTAL ASSISTANCE - DEPENDS TOTALLY ON OTHERS FOR BATHING |
MOBILITY
INDEPENDENT
- MOVES AROUND WITH NO ASSISTANCE
MINIMUM - USES ASSISTIVE DEVICES (WALKER/CANE)
MODERATE - STAND BY ASSISTANCE
MAXIMUM
TOTAL ASSISTANCE - DEPENDS COMPLETELY ON OTHERS, IS LIFTED |
ELIMINATION
INDEPENDENT - USES THE BATHROOM WITHOUT ANY ASSISTANCE
MINIMUM - USES INCONTINENT PRODUCTS
MODERATE - OCCASIONAL INCONTINENCE, NEEDS VERBAL CUES
MAXIMUM - FREQUENT INCONTINENCE OF BOWEL/BLADDER,
CATHETER
TOTAL ASSISTANCE - INCONTINENT, DEPENDENT ON OTHERS. |
FALLS
NO FALLS IN THE LAST 12 MONTHS
ONE FALL IN THE LAST 12 MONTHS, WITHOUT INJURY
TWO OR MORE FALLS IN THE LAST 12 MONTHS, WITHOUT INJURY
TWO OR MORE FALLS IN THE LAST 12 MONTHS, WITH INJURY
FREQUENT FALLS, UNSAFE |
|
