Application For Residency (Page 3 of 3) in pdf

Application For Residency Page 3

How much walking do you do?

Do you have difficulty with stairs?

Yes

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

Please list all of your medical insurance coverage's, including supplemental and long term care:

Policy No.

(please provide us with copies of your insurance cards)

V. Daily Living

Please use an "X" to indicate your level of ability in the following areas:

"I can handle

"I need some

Task

this myself"

assistance"

Comments

Bathing

Dressing

Mouth or Skin Care

Shaving or Grooming

Toileting

Escort/Mobility

Med Reminder

Night Care

Hskg/Clothing Mgt.

Do you have hobbies, or areas of special interest to you?

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

I understand and agree this application is neither a contract, nor a reservation for residence. Nothing

contained in this document is legally binding on either myself or the community to which I am applying

for residency, until a Residency Agreement has been approved and signed by all parties involved.

Signature of Applicant

Date of Application

Application For Residency Page 3