Admission Form - Senior Health Care, Inc.

Download PDF of Admission Form

For SHC Use Only:

Date of Admission:
Facility:

RESIDENT (PRINT):

Last:

DOB:

First:

Race:

Sex:

Male

Female

Religion:

PLACE OF ORIGIN:

Facility:

Street:
City:
ST/Zip:
Cell:

Unit:
Contact:
Phone:
Fax:

Classification

Attending Physician

	Home
	Hospital
	Rehabitilation
	Assisted Living
	Nursing Home
	Hospice

Name:
Phone:
Fax:
Cell:
Email:

SOCIAL SEC. #
MEDICARE ID:
MEDICAID ID:
INSURANCE ID:
VA ID:

EMERGENCY CONTACT:

Name:
Relationship:
Phone (H):
Phone (W):
Cell:

POWER OF ATTORNEY (POA):

Name:
Relationship:
Phone:
Cell:

MEDICAL HISTORY:

DIAGNOSIS

MEDICATIONS

DOSE

SPECIAL CONDITIONS

1:
2:
3:
4:
5:

1:
2:
3:
4:
5:

Physical Limitations	Yes	No
Dementia / Alzheimer	Yes	No
Behavior / Mental Conditions	Yes	No
Dietary Restrictions	Yes	No
Other (Please attach description)	Yes	No

KNOWN ALLERGIES (if any)

SERVICE REQUIREMENTS:

Bathing:	Yes	No
Grooming:	Yes	No
Cleaning:	Yes	No
Dressing:	Yes	No
Laundry:	Yes	No
Feeding:	Yes	No

Daily Meals :	Yes	No
Special Diet :	Yes	No
Wheel Chair:	Yes	No
Special Bed :	Yes	No
Oxygen:	Yes	No
Insulin:	Yes	No

Supplies (e.g. Diaper):	Yes	No
Medication Assistance:	Yes	No
Doctor's Appoinments:	Yes	No
Day Care Service :	Yes	No
Transportation:	Yes	No
Other:	Yes	No

Private Room :	Yes	No
Private Bath :	Yes	No
Shared Room :	Yes	No
Shared Bath :	Yes	No
Other:	Yes	No

PERSONAL INTERESTS:

Music:	Yes	No
Paintings:	Yes	No
Crafts:	Yes	No
Activities:	Yes	No
Hobbies:	Yes	No
Others:	Yes	No

SERVICE PERIOD:

	Short-term ( 91Days - 2 Years)
	Long Term ( > 2 Years)

Respite Care (days):

	< 7
	8 -14
	15 -30
	31 -60
	61 - 90

SOURCE OF PAYMENT:

	Private Fund
	Veteran Administration
	SSB
	Medicaid
	County Subsidy

OTHER PERTINENT INFORMATION:

Life Insurance	Yes	No	If yes policy no.
DNR	Yes	No	If Yes, attach copy
Funeral Arrangement	Yes	No	If Yes, Provide details
Organ Donation	Yes	No	If Yes, which organ/s?
A Personal Will	Yes	No	If Yes, attach copy

I consent to act as emergency contact for , resident, which entails being responsible for making decisions in the event of an emergency which specific nature of care the resident will be given.

Completed By:

Print Name:

Signature of Responsible Party or POA

Date