Name (required): Address 1: Address 2: City: State: Zip: Phone: Email: Date of birth: Place of birth: Marital status: Living Situation: Living aloneWith family membersWith caregivers 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: YesNo Living will: YesNo Do not resuscitate: YesNo Do not hospitalize: YesNo 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: YesNo If Yes, where: Enjoys religious interaction: YesNo If Yes, specify: PERSONAL PREFERENCES Daily contact with family: YesNo Daily contact with close friends: YesNo Daily animal companion/presence: YesNo Most time alone: YesNo Enjoys TV: YesNo Gets dressed daily: YesNo Bedclothes most of day: YesNo Normal bedtime hour: Naps regularly: YesNo Showers for bathing: YesNo Bathtub: YesNo Leaves home during week one or more times: YesNo Has hobbies, reads, daily routines: YesNo Likes group activities: YesNo Ambulates independently: YesNo Uses appliances: YesNo If yes, specify appliance(s) used: Uses alcohol: YesNo Uses tobacco: YesNo Distinct food preferences: YesNo If yes to above, specify: Eats between meals all or most days: YesNo Wakens to toilet all or most nights: YesNo Irregular bowel movements: YesNo Additional comments: