Application For Residency Page 2
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1
2
3Regular assisted living
Memory care assisted living
Other
Do you own an automobile?
Yes
No
Make and Year
Do you drive regularly?
Yes
No
Do you intend to maintain a car?
Yes
No
Are there any problems or concerns our staff should be aware of, or any special support you might need
in our community?
Do you require someone (friend, relative, or other person) to live with you at the present time?
If so, who?
Reason for this need?
If not, do you require someone to visit you during the day?
Yes
No
If yes, reason for a visit?
How long is a visit?
Are you considering other housing alternatives?
Yes
No
If so, which ones?
IV. Medical and Insurance Information
Primary Physician's name:
Address
Telephone
Hospital Affiliation:
Secondary or Other Physician's name:
Address
Telephone
Hospital Affiliation:
How would you describe your present state of health?
How often do you see your doctor?
When was your last visit?
Are you on any medications at the present time?
Yes
No
If yes, please specify the medication and condition being treated:
Do you require assistance to administer the medications?
Yes
No
Do you prepare your own meals?
Yes
No If no, who does?
Are you on a special or restricted diet?
Yes
No If yes, please describe
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