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Admission Form
Resident Print
First Name
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Last Name
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Sex
Male
Female
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B.O.D
Select
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Race
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Religion
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Place of Origin
Facility
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Street
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City
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ST/Zip
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Cell Number
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Unit
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Phone
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Fax
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Classification
Home
Hospital
Rehabitilation
Assisted Living
Nursing Home
Hospice
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Attending Physician
Name
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Phone
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Fax
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Cell Number
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Email
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Medical History
Diagnosis History
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Diagnosis History
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Medications History
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Medications History
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Dose
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Dose
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Special Conditions
Physical Limitations
Yes
No
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Dementia / Alzheimer
Yes
No
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Dietary Restrictions
Yes
No
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Behavior / Mental Conditions
Yes
No
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Other (Please attach description)
Yes
No
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Known Allergies (if any)
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Service Requirements
Bathing
Yes
No
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Grooming
Yes
No
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Cleaning
Yes
No
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Dressing
Yes
No
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Laundry
Yes
No
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Feeding
Yes
No
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Daily Meals
Yes
No
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Special Diet
Yes
No
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Wheel Chair
Yes
No
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Special Bed
Yes
No
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Oxygen
Yes
No
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Insulin
Yes
No
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Supplies (e.g. Diaper)
Yes
No
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Medication Assistance
Yes
No
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Doctor's Appoinments
Yes
No
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Day Care Service
Yes
No
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Transportation
Yes
No
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Other
Yes
No
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Private Room
Yes
No
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Private Bath
Yes
No
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Shared Room
Yes
No
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Shared Bath
Yes
no
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Other
Yes
No
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Personal Interests
Music
Yes
No
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Paintings
Yes
No
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Crafts
Yes
No
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Activities
Yes
No
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Hobbies
Yes
No
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Others
Yes
No
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Service Period
Short-term ( 91Days - 2 Years)
Long Term ( > 2 Years)
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Respite Care (days)
< 7
8 -14
15 -30
31 -60
61 - 90
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Source of Payment
Private Fund
Veteran Administration
SSB
Medicaid
County Subsidy
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Other Pertinent Information
Life Insurance
Yes
No
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If yes policy no
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DNR
Yes
No
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If Yes, attach copy
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Funeral Arrangement
Yes
No
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If Yes, Provide details
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Organ Donation
Yes
No
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If Yes, which organ/s?
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A Personal Will
Yes
No
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If Yes, attach copy
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