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Name: Address: City: State: Zip: Phone: Email:
Relationship with the person needing care: Father Mother Sister Brother Aunt/Uncle Friend
Enter His or Her Name:
Enter His or Her age:
Where do you/they currently live?
What existing medical conditions does this person have?(Select all that apply.)
None Alzheimer's/Dementia Arthritis Cancer Eye Disease
Heart Disease HIV/AIDS High Blood Pressure Hypertension
Incontinence Stroke Osteoporosis Surgery Parkinson's
Respiratory Disease High Cholesterol Depression Diabetes
Describe this person's ability to dress, bath and groom:
Maintains a good level of hygine, dresses in appropriate clothes Needs assistance - needs reminders or help to dress, bath... Is dependent on someon else to dress or bath him or her
Describe this person's mobility: Walks without any assistance Needs a cane, walker, or the help of another person Requires complete assistance
Describe this person's ability to remember: Has awareness of date, time, perso nand place Needs frequent verbal cues and reminders Is unaware of person, place or time
Describe this person's ability to take medication: Takes own medication without any reminders Needs reminders or supervision Unable to take medication safely
What is most important to you?
Atmosphere / Comfort Level Equipement &Amenities Financial Considerations Safety provisions Services & Activities Staff & Residents
How long do you need these care services?
1 Week 1 Month Long Term
When would you like this care to begin?
As soon as possible A week A month Future
What is your room preferance?
PrivateRoom Semi-Private Room
Comments:
