Woodstock Vermont Nursing Care Facility - Mertens House Vermont Long Term Nursing Care


PRE-ADMISSION APPLICATION

Name: 
Address 1: 
Address 2: 
City: 
State: 
Zip: 
Phone: 
Email: 
Date of birth: 
Place of birth: 
Marital status: 
Living Situation: 

Nearest relative/contact
Significant others/relationship
Caregiver(s)
Current care facility/type
Current care facility contact
Dates of prior nursing home stays
Health reasons for needing nursing home placement
Power of attorney for healthcare
Power of attorney for finance

Advance directives:  Yes   No
Living will:  Yes   No
Do not resuscitate:  Yes   No
Do not hospitalize:  Yes   No

Feeding restrictions
Medications restrictions
Other treatment restrictions
If hospitalized, preference

Current Physician: 
Physician's Phone: 
Dentist: 
Eye Doctor: 
Medicare Number: 
Supplemental Health Insurance: 
Group Number: 
Certificate Number: 
Prescription Insurance: 
Group Number: 
Certificate Number: 

Highest level of education: 
Lifetime occupation: 
Religious preference: 
Attends church/temple/synagogue:  Yes   No
If Yes, where: 
Enjoys religious interaction  Yes   No
If Yes, specify: 

PERSONAL PREFERENCES

Daily contact with family:  Yes   No
Daily contact with close friends:  Yes   No
Daily animal companion/presence:  Yes   No
Most time alone:  Yes   No
Enjoys TV:  Yes   No
Gets dressed daily:  Yes   No
Bedclothes most of day:  Yes   No
Normal bedtime hour: 
Naps regularly:  Yes   No
Showers for bathing:  Yes   No
Bathtub:  Morning   Evening
Leaves home during week one or more times:  Yes   No
Has hobbies, reads, daily routines:  Yes   No
Likes group activities:  Yes   No
Ambulates independently:  Yes   No
Uses appliances:  Yes   No
If yes, specify appliance(s) used
Uses alcohol:  No   Daily   Weekly
Uses tobacco:  Yes   No
Distinct food preferences:  Yes   No
If yes to above, specify
Eats between meals all or most days:  Yes   No
Wakens to toilet all or most nights:  Yes   No
Irregular bowel movements:  Yes   No

Additional comments


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