General Information

 

Full Name *

Current Address (required)




Date of Birth

Place of Birth

Marital Status

Spouse's Name

Number of Living Children

Religious Affiliation

Name and Address of Church

Pastor Phone Number:

Church Phone Number:

Hobbies and Interests

 


 

History

 

Occupation(s):

Clubs, Organizations and Memberships

 


 

Present Physicians

 

Doctor's Name:

Phone Number:

Address:




Dentist's Name:

Address:




Phone Number:

Is The Applicant Scheduled For Any Future Doctor's Appointments That The Braley Care Staff Should Be Aware Of?
YesNo

If Yes, Please Name The Physician(s), Along With The Date And Time Of Appointment:

 


 

Medical Information

 

Known Allergies

Is The Applicant Confined In A Hospital Or Nursing Home?
YesNo

If Yes, What Is The Name And Address Of The Facility?

For What Reason(s)?

List Of Current Medications

 


 

Present Physical Condition

 

Applicant's Present Diagnoses

Primary

Secondary

Has There Been A Drastic Weight Loss?
YesNo

 

Does The Applicant Have Dentures?
UpperLowerFull

 

Control Of Bowels?
YesNo

 

Control Of Bladder?
YesNo
 

Does The Applicant Have Any Self-Managing Colostomies, Urostomies, Or Catheters?
YesNo

 

Frequent Diarrhea?
YesNo

 

Frequent Constipation?
YesNo

 

Is There Any Other Medical Or Health Information Braley Care Homes Should Know About This Applicant?

Is The Resident "CODE" Or "NO CODE"?
CODENO CODEUnsure

 


 

Psychological Information

 

Is The Applicant Generally Able To Communicate Clearly?
YesNo

 

Is The Applicant Generally Alert Or Confused?
AlertConfused

 

How Does The Applicant Feel About Receiving In-Home Service?

How Does The Applicant Spend Their Time?

The Applicant Seems (check all that apply)
DepressedAngryCheerfulFearfulContentConfusedCombativeWonders

 


 

Other Information

 

Each resident shall have a written, signed and dated health assessment by a physician or other licensed health care professional, authorized under the state law to perform this assessment, not more then sixty (60) days prior to the residents admission, or no more than five (5) working days following admission, and at least annually after that. The admission and annual health assessment shall include screening for tuberculosis and other communicable diseases if indicated by exposure, prevalence or risk according to current medial practice in congregate living situations as indicated by the secretary.

 

Responsible Parties To Be Notified In Case Of Emergency, Discharge Or Demise Of The Resident:

 

NAME

Relationship

Address

Phone Number

Does The Applicant Have Legal Representation?
YesNo
 
 

Check If Applicant Has Any Of The Following:


 

A Guardian

YesNo

If Yes, Give Name, Address And Phone Number

Medical Power Of Attorney
YesNo

If Yes, Give Name, Address And Phone Number

Power Of Attorney
YesNo

If Yes, Give Name, Address And Phone Number

Durable Power Of Attorney
YesNo

If Yes, Give Name, Address And Phone Number

A Living Will
YesNo

 

Resuscitation Directives
Yesno

List Any Person, Agency Or Organization Responsible For Payments Of The Resident

List Any Special Directions

 


 

Insurance Information

 

Insurance Company

Address:




Policy #

Group #

Payor #

 
 
* Please note that Braley Care Homes will ask for copies of the applicant's insurance cards, Social Security card, MPOA, POA, Living Will and DNR (if applicable).