Application For Admission

Application For Admission
Full Name *
Date *

Day Month Year
Date
Email *
example@example.com
Phone *
SS#
MEDICAID#
MEDICARE#
Date Of Birth
Age
Place Of Birth
Current Living Situation
City
County
Support
STATUS

Married Single Divorced Widowed
HOW LONG *
Person Assisting with Application
Relationship
POA, GUARDIAN
Name
Relationship
Status
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone
Friends, Relatives, Emergency Contacts
Name
Relationship
Phone
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Name
Relationship
Phone
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Name
Relationship
Phone
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
SOURCE OF FUNDS

Private Medicaid Innovage VA Other
Benefits County of Record
File Complete

Yes No
CASE MANAGERS
Name
Phone
Entity
Name
Phone
Entity
PHYSICIAN INFORMATION
Primary Doctor
Phone
Fax
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Specialist Doctor
Phone
Fax
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Specialist Doctor
Phone
Fax
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Psych Doctor
Phone
Fax
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
MOBILITY
HOW FAR CAN YOU WALK (W/O ASSISTANCE) BEFORE YOU HAVE TO STOP AND REST?

10ft or less Across a room (10-20ft) 20ft to 1 Block 1 Block or more
PLEASE LIST ANY ASSISTIVE DEVISES YOU USE

NOTHING CANE WALKER WHEELCHAIR
Do you currently drive a car?

Yes No
Time *

DAY NIGHT BOTH
BATHING
I BATHE IN SHOWER W/O ASSISTANCE

Yes No
I NEED HELP GETTING IN/OUT SHOWER

Yes No
I USE A SHOWER CHAIR

Yes No
I NEED HELP WASHING PARTS OF MY BODY

Yes No
I NEED HELP WASHING MY HAIR

Yes No
DRESSING
I CAN DRESS MYSELF W/O HELP

Yes No
I NEED HELP PUTTING ON SOCK/SHOES

Yes No
I NEED HELP W/ZIPPERS & BUTTONS

Yes No
I NEED HELP W/ALL CLOTHING/SHOES

Yes No
DINING
WHEN I EAT, I HAVE DIFFICULTY (CHECK ALL THAT APPLY)

FEEDING MYSELF CUTTING MY FOOD SWALLOWING CHEWING I HAVE SHAKEY HANDS I NEED SOMEONE TO FEED ME OTHER
TOILETING

I HAVE PROBLEMS CONTROLLING MY :
BLADDER

NEVER SOMETIMES OFTEN NIGHT ONLY
BOWELS

NEVER SOMETIMES OFTEN NIGHT ONLY
DO YOU MANAGE INCONTINENCES WITH

DEPENDS PADS CATHETER OTHER
DO YOU NEED HELP CHANGING AND CLEANING UP

Yes No
CAN YOU GET TO THE BATHROOM AT NIGHT

Yes No
SLEEP
What time do you like to go to bed?
Do you sleep through the night?

Yes No
How often do you wake up at night? *
Why
Do you take a sleep aid? *
What kind? *
What time do you wake up?
ARE YOU CURRENTLY EMPLOYED OR VOLUNTEERDo you stay in bed or get up?
VISION/HEARING
I WEAR HEARING AIDS

Yes No
I CAN HEAR W/O A HEARING AID

Yes No
I CAN HEAR TO USE TELEPHONE

Yes No
I CAN PUSH BUTTONS ON PHONE

Yes No
I WEAR GLASSES FOR

READING DISTANCE BOTH NONE
SPEAKING/WRITING
I CAN READ

STANDARD PRINT LARGE PRINT ONLY
I AM LEGALLY / TOTALLY BLIND

Yes No
MY SPEECH IS DIFFICULT TO UNDERSTAND

Yes No
I CAN WRITE

Yes No
I CAN UNDERSTAND OTHER PEOPLE

Yes No
SOCIALIZATION/PRIVACY
ARE YOU CURRENTLY EMPLOYED OR VOLUNTEER *

Yes No
HOW LONG *
Where
Phone
HOW IMPORTANT IS YOUR PRIVACY

VERY SOMEWHAT NOT VERY
HOW OFTEN DO YOU SEE OR CHAT WITH FRIENDS/NEIGHBOR WHO DO NOT LIVE WITH YOU

SEVERAL TIMES A DAY ONCE A DAY FEW TIMES A WEEK LESS THAN ONCE A WEEK
DO YOU BELONG TO ANY CLUBS, CHURCHES, and ETC *

Yes No
PLEASE LIST THEM *
PLEASE LIST SOME OF YOUR HOBBIES
DO YOU ENJOY LIFE

MOSTLY SOME SELDOM
DO YOU FEEL LIKE A BURDEN TO OTHERS

NEVER FREQUENTLY OCCASIONALLY
HOW DO YOU USUALLY SPEND YOUR TIME
IN THE EVENINGS
DO YOU DO YOUR OWN SHOPPING *

Yes No
IF NO WHO HELPS YOU
I HAVE DIFFICULTY REMEMBERING WHAT HAPPENED YESTERDAY BUT I CAN REMEMBER WHAT HAPPENED ALONG TIME AGO

Yes No
I SMOKE *

Yes No
HOW MUCH
I DRINK ALCHOL *

Yes No
HOW OFTEN
PHYSICAL HEALTH
MY HEALTH PROBLEMS ARE
I TAKE MEDICATIONS

W/O REMINDER IF SOMEONE REMINDS ME IF THEY ARE GIVEN TO ME I DO NOT TAKE REGULAR MEDICINE
WHEN WAS YOUR LAST HOSPITAL STAY? *
WHY
WHEN WAS YOUR LAST VISIT TO EMERGENCY ROOM? *
WHY
ARE YOU ON A SPECIAL DIET *

YES NO
DESCRIBE
DO YOU HAVE ANY FOOD/MEDICATION ALLERGIES
WHEN WAS THE LAST TIME YOU HAD HOME HEALTH
WHY
ADDITIONAL INFORMATION
MY COMMENTS AND CONCERNS ARE
TO THE BEST OF MY KNOWLEDGE, ALL THE ABOVE INFORMATION IS ACCURATE
AND COMPLETE.
Date

Month Day Year
Date
SIGNATURE OF APPLICANT *

Clear
Date

Month Day Year
Date
SIGNATURE OF PERSON ASSISTING *

Clear
Should be Empty:

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Application For Admission

POA, GUARDIAN

Friends, Relatives, Emergency Contacts

CASE MANAGERS

PHYSICIAN INFORMATION

MOBILITY

BATHING

DRESSING

DINING

TOILETING

SLEEP

VISION/HEARING

SPEAKING/WRITING

SOCIALIZATION/PRIVACY

PHYSICAL HEALTH

ADDITIONAL INFORMATION