Medical Evaluation Form - Group Homes printable pdf download

MEDICAL EVALUATION FORM

• This Form needs to be completed by the prospective resident’s Medical Officer.

• The Admission Form and Medical Form must be returned together.

• Every Application is assessed on this report and interview.

• Lack of information may cause delay in the assessment.

Surname:

_____________________________________________________________

Given Name(s):

______________________________________________________________

Current Address:

___________________________________________________________

_______________________________________________

Postcode: _________________

Medicare Number: ____________________________ Expiry Date: ______________________

Pharmaceuticals Benefits Number: ___________________ Pension Number: _________________

Health Fund:

______________________________________________________________

Country of Birth:

Date of Birth: ______________________

_______________________

Marital Status: __________________________________________________________

PERSON RESPONSIBLE TO CONTACT IN EMERGENCY:

(an emergency is a significant change in the resident’s medical condition)

Name: ______________________________________________________________________

Relationship to you: ___________________________________________________________

Address: ___________________________________________________________________

____________________________________________ Postcode: ____________________

Phone Numbers: Home: ______________________

Business: _____________________

Mobile: ____________________________________

DETAILS OF DOCTOR COMPLETING FORM:

Name: __________________________________________________________________________

Address: ________________________________________________________________________

_________________________________________________________ Postcode: ______________

Phone: _______________________________ Phone: ___________________________________

Length of time he/she has known applicant: _____________________________________________

Is applicant presently at:

Home

Hospital

Nursing Home

Other Accommodation

MEDICAL EVALUATION FORM.doc

Medical Evaluation Form - Group Homes