Resident
Information
Chart
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Potential Resident's Physical and
Medical Conditions

Resident's Information Chart

Name of Potential Resident:

Mr. / Ms. Age:

Current residency:

    Live independently at home.
      Live at home with companion, relative, and / or care giver.
      Live in a community retirement inn / assisted living facility.


    Live in a residential care facility. (FRCE)

    Live in a skilled nursing facility.

    Address:

    street:
        city:
     state: zip code:

    Name of facility (if applicable):

Resident's Condition:

    A. Physical:

      Ambulatory (resident needs assistants for mobility ie., cane / wheelchair,etc)
      Non-Ambulatory

    B. Cognition: potentially resident suffers from:

        Depression.
        Forgetfulness.
        Dementia.
        Alzheimer.

    C. Medical: potentially resident suffers from:
Disease Date Diagnosed: recovered:
  Cancer
yes no
  Stroke yes no
  Heart problems yes no
  Breathing Disorder yes no
  Require Catheter
Care		 yes no
  Bowel / Bladder
Incontinence		 yes no
  Behavioral
Disorder		 yes no
  Neurological
Disorder

 yes no
Additional Disease(s) not mentioned above
  yes no
  yes no
 
yes no

    D. Medication: List all medications currently being used:
Name of Medication Dosage Consumption per Day


Please fill out the above form, print it, and fax to [650-348-8690]
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