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General Information (Applicant Information)
 
Name: ____________________
Address: ____________________
City: ____________________
State: ____________________
Zipcode: ____________________
Marital Status: ____________________
Term Choice: Short ___ Long ___
Still Drive? Yes ___ No ___
 
Date of Birth: __________________
Desired Date of Residency:
  __________________
Home Phone: __________________
Social Sec #: __________________
Sex (M or F): __________________
Doctor: __________________
Bring Car? __________________
 
 
Contact Party (Closest Relatives)
 
Name: ____________________
Address: ____________________
City: ____________________
State: ____________________
Zipcode: ____________________
Phone: ____________________
Relationship: ____________________
Name: ____________________
Address: ____________________
City: ____________________
State: ____________________
Zipcode: ____________________
Phone: ____________________
Relationship: ____________________
 
 
Resident Medical Information
 
Recent: ________________________________________________________
________________________________________________________
________________________________________________________
Past: ________________________________________________________
________________________________________________________
________________________________________________________
Current Medications: ______________________________________________
 
Smoker: Yes ___ No ___   Drink Alcohol: Yes ___ No ___  
Does Resident Use: Cane ___ Walker ___ Wheelchair ___ None ___  
Continent of: Urine ___ Stool ___ Frequency of Problem: ____ / week
Medical Insurance Provider: ______________________________________
 
Financial Information
 
Monthly Income From: Social Security $________
Pension $________
Other $________
Total $________
Drug Payment Plan (PACE, etc.): __________________________________
 
 

 
Grand View Manor, 129 Houck Road, Fleetwood, PA 19522
Phone: (610) 944-1800   Toll Free: (866) 944-1800   Fax: (610) 944-5200
© Copyright Assured Care, Inc. 2002, All Rights Reserved, Contact Us