Application For Admission To The New York Armenian Home Page 10
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10LIST ALL CURRENT MEDICATIONS (PRESCRIPTION AND OTC) AND NOTE SPECIAL INSTRUCTION
MEDICATION (Type, Frequency and Dosage)
SECTION IV: OBSERVATION OF INDIVIDUAL
IS INDIVIDUAL: (PLEASE CHECK EITHER YES OR NO)
YES
NO
DESCRIBE AS NEEDED
AMBULATORY?
CAPABLE OF SELF-ADMINISTRATION OF
MEDICATIONS?
HABITUATED TO DRUGS?
HABITUATED TO ALCOHOL?
DANGER TO SELF OR OTHERS?
FREE OF COMMUNICABLE DISEASE?
INCONTINENT?
SECTION V: EVALUATION
IN YOUR OPINION CAN THE INDIVIDUAL’S NEED BE MET BY THE SUPPORT SERVICES AVAILABLE IN AN ADULT CARE FACILITY?
___ YES
___ NO (PLEASE DESCRIBE OPTIONAL)
DOES THE INDIVIDUAL REQUIRE PLACEMENT IN A NURSING FACILITY?
___ YES
___ NO (IF YES, PLEASE GIVE REASONS)
DOES THE INDIVIDUAL HAVE A RELEVANT HISTORY, CURRENT CONDITION OR RECENT HOSPITALIZATION FOR MENTAL ILLNESS?
___ YES
___ NO (IF YES, EXPLAIN)
IF YES TO THE ABOVE QUESTION, DOES THE INDIVIDUAL REQUIRE A MENTAL HEALTH EVALUATION?
___ YES
___ NO
PHYSICIANS SIGNATURE:
DATE OF EXAMINATION:
FORM COMPLETED:
_______________________________
_________/ _________/ _________
_________/ _________/ ________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application For Admission To The Roster Of Accountants Authorized To Conduct Municipal Audits - Oregon Board Of Accountancy
Legal
Form 3 - Connecticut Bar Examining Committee Amendment To Application For Admission To The Bar By Examination
Legal
Renewal Application For Admission To The Roster Of Accountants Authorized To Conduct Municipal Audits - Oregon Board Of Accountancy
Legal
Instructions For Form Ft-1006 - Application For Refund Of The New York State Diesel Motor Fuel Tax By An Omnibus Carrier
Business
Related Categories
Parent category: Business