1. PROSPECTIVE CLIENT'S NAME:
2. POWER OF ATTORNEY / RESPONSIBLE PERSON:
3. TELEPHONE #:
4. HOW DID YOU HEAR ABOUT THE VILLA?
5. ADDRESS:
6. E-MAIL:
7. CLIENT'S AGE:
8. DATE OF BIRTH:
9. MALE/FEMALE:
MaleFemale
10. EXPECTED MOVE IN DATE:
11. DEMENTIA/ALZHEIMER (YES/NO):
YesNo
12. WEIGHT:
13. AMBULATORY/NON AMBULATORY:
AmbulatoryNon Ambulatory
14. WHEELCHAIR/WALKER:
15. BEDRIDDEN (YES/NO):
16. INCONTINENT (YES/NO):
17. VERBAL/PHYSICAL COMBATIVE (YES/NO):
18. SUNDOWNER (YES/NO):
19. WANDERER (YES/NO):
20. DIALYSIS (YES/NO):
21. HEARING IMPAIRED (YES/NO):
22. SIGHT IMPAIRED (YES/NO):
23. DIABETIC (YES/NO):
24. IF DIABETIC, INSULIN OR ORAL? (ANSWER NOT APPLICABLE IF NOT DIABETIC):
InsulinOralNot Applicable
25. OXYGEN TANK (YES/NO):
26. CATHETER (YES/NO):
27. OSTOMY (YES/NO):
28. CURRENT OPEN WOUNDS (YES/NO):
IF THE CLIENT HAS OPEN WOUNDS PLEASE EXPLAIN (OPTIONAL):
29. SMOKE (YES/NO):
30. MEDICATION MANAGEMENT (YES/NO):
31. FEEDING ASSISTANCE (YES/NO):
32. BATHING & DRESSING & GROOMING ASSISTANCE (YES/NO):
33. RECENT/PAST INJURIES OR SURGERIES (YES/NO):
IF THE CLIENT HAS RECENT/PAST INJURIES OR SURGERIES PLEASE EXPLAIN (OPTIONAL):
GENERAL DESCRIPTION:
Name*
E-mail*
Phone*
Message*
