Form Dhsr/ac 4207 - Resident Register (Page 2 of 4) in pdf

Form Dhsr/ac 4207 - Resident Register Page 2

DHSR/AC 4207 (Rev. 09/11) NCDHHS

2. PREVIOUS PHYSICIAN_______________________________________________________________________________

Phone (

)

Address______________________________________________________________________________________________

PLANS MADE FOR PAYMENT OF: Personal Needs________________________________________________________

Other________________________________________________________________________________________________

C. PERSONAL INFORMATION

1. ASSISTANCE REQUIRED FOR: (Check all that apply)

 Dressing

 Correspondence

 Mouth Care

 Bathing

 Getting In/Out of Bed

 Feeding

 Nail Care

 Toileting

 Positioning/Turning

 Shaving

 Hair/Grooming

 Scheduling Appointments

 Ambulation

 Skin Care

 Orientation to Time and Place

 (Other)_____________________________________________________________________________________

If different from information contained on the FL-2, home must contact resident’s physician for clarification.

 Adequate

 Forgetful – Needs Reminders

 Significant Loss – Must Be Directed

MEMORY:

3. SPECIAL AIDS: (Check all that apply)

 Walker

 Hearing Aid

 Wheelchair

 Eyeglasses

 Dentures (Type)______________

 Other____________________________

4. PERSONAL HABITS:  Smoking

 Alcohol

 Other___________________________________________

5. KNOWN ALLERGIES OR SUBSTANCES NOT TO BE ADMINISTERED (Drug, Food, or Otherwise):

6. FOOD PREFERENCES: If special diet, please describe:_______________________________________________________

____________________________________________________________________________________________________

FAVORITES

LEAST FAVORITES

Vegetable

Fruit

Meats

Meat Substitutes

Cereals and Breads

Milk or Buttermilk

Other Beverages

7. COMMUNITY INVOLVEMENT

FAITH COMMUNITY___________________________________ PASTOR___________________________________

Phone (

)

Address__________________________________________________________________________________________

b. CLUB, GROUP OR ORGANIZATIONAL MEMBERSHIPS_______________________________________________

SPECIAL SKILLS OR TALENTS_____________________________________________________________________

Form Dhsr/ac 4207 - Resident Register Page 2

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