Charlton Manor Rest Home

I. General Information

Applicant Name

(Last)

(MI)

(First)

Address

How long at this Address? (yrs)

City

State

ZIP Code

Telephone where applicant can be reached?

Gender

Date of Birth

Birth place

Phone #

Social Security #

II. Resident Profile

Spouse's Name

Spouse's Date of Birth

If Spouse is deceased, date and cause of death

Former Occupation

Length of employment

Date of retirement

Religion

Church

In case of an emergency or a necessity, whom should we call?

Name

Relationship

Address

State

ZIP Code

Phone #

Name

Relationship

Address

State

ZIP Code

Phone #

Next of Kin (if different than above)

Name

Relationship

Address

State

ZIP Code

Phone #

Name

Relationship

Address

State

ZIP Code

Phone #

III. Current Living Situation

Do you currently own your own home or rent?

What type of housing do you live in?

Make and Year

Are there any problems or concerns that our staff should be aware of, or any special support you might need to live in our community?

IV. Medical and Insurance Information

Physician's name

Address

State

ZIP Code

Phone #

Hospital Affiliation

How would you describe your present state of health?

Do you have any allergies to food or medicine?

How often do you see your doctor?

If Yes, please describe

How much walking do you do?

Do you have any difficulty with stairs?

Do you use any assistance such as a cane, walker, or wheelchair?

Type

Please list all of your medical insurance coverages, including supplemental and long-term care

Policy #1

Coverage Description

Policy No.

Policy #2

Coverage Description

Policy No.

V. Daily Living

Comments

Do you fill your own prescriptions?

If you need a medicine reminder, will you be using the pharmacy Charlton Manor uses to deliver prescriptions?

Is there any other information we should be aware of when reviewing your health and medical concerns?

Mental Status

Alert

Forgetful

Anxious

Aware of time/place

Has applicant been diagnosed with Alzheimer's Disease?

Dementia?

Has applicant been diagnosed as mentally ill or mentally retarded?

Please describe temperament of applicant

What are your personal strengths and interests?

How do you like to spend your time?

Income Sources

The following worksheet is necessary to determine if your financial resources are adequate to cover the monthly living costs at Charlton Manor Rest Home. This information is kept confidential and can be used to determine if you may be eligible for our Medicaid program.

Employment Income ($ per month)

Social Security ($ per month)

Employer Pension ($ per month)

Life Insurance Benefits ($ per month)

Annuity Income ($ per month)

Support from Family ($ per month)

Interest & Dividend Income ($ per month)

Other ($ per month)

Total Monthly Income ($ per month)

Please List Any Bank Accounts

Add Another Bank Account

Name and address of "Other Person"

Name

Phone #

Address

City

State

ZIP Code

Relationship (e.g. Power of Attorney, Conservatorship)

Please describe any Advance Directives you may have in place (i.e. power of attorney, health care proxy, DNR, living will, conservator, guardian) and list name, address, and phone number of person who holds such power. Please furnish a complete copy of the authorizing document, as well as any trust documents, wills and codicils which may pertain to these powers.

Add another Advance Directive

I certify that the information I have given in this application is true and correct. I understand that any false statements, misrepresentations or omissions may result in the cancellation of my application. All information submitted by the applicant will be held in strict confidence.

Applicant Signature (Type Full Name)

Date

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