Name (required):

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:

Living will:

Do not resuscitate:

Do not hospitalize:

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:

If Yes, where:

Enjoys religious interaction:

If Yes, specify:

Daily contact with family:

Daily contact with close friends:

Daily animal companion/presence:

Most time alone:

Enjoys TV:

Gets dressed daily:

Bedclothes most of day:

Normal bedtime hour:

Naps regularly:

Showers for bathing:

Bathtub:

Leaves home during week one or more times:

Has hobbies, reads, daily routines:

Likes group activities:

Ambulates independently:

Uses appliances:

If yes, specify appliance(s) used:

Uses alcohol:

Uses tobacco:

Distinct food preferences:

If yes to above, specify:

Eats between meals all or most days:

Wakens to toilet all or most nights:

Irregular bowel movements:

Additional comments: