Application for Residency - Hiawatha Care Center

1
Application Date:* This field is required.
Date
Month
Day
Year
2
Anticipated Admission Date:* This field is required.
Date
Month
Day
Year
3
Patient Name:* This field is required.
First Name
Middle Name
Last Name
4
Patient Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Patient Phone Number:* This field is required.
Area Code
Phone Number
6
Patient Date of Birth:* This field is required.
Month
Day
Year
7
Patient Age:* This field is required.
8
Patient Gender:* This field is required.
Male
Female
9
Patient SSN #* This field is required.
10
Patient Marital Status:
Please Select
Please Select
Single
Married
Widowed
Divorced
11
Patient Lifetime Occupation
12
Referred by
13
Insurance Information / Other Insurance Information
Medicare #
Medicaid (T19) #
Prescription Insurance Plan
Policy #
Medicare Supplement
Policy #
Long-Term Care Insurance
Policy #
14
Veteran?* This field is required.
YESNO
15
Spouse of a Veteran?* This field is required.
YESNO
16
Receiving VA Benefits?* This field is required.
YESNO
17
Emergency Contact Information:
Full Name
Address
Home Phone #
Cell Phone #
Work Phone #
Email Address
Relationship
18
Billing Contact Information:
Full Name
Address
Home Phone #
Cell Phone #
Work Phone #
Email Address
Relationship
19
Additional Contact Information 1:
Full Name
Address
Home Phone #
Cell Phone #
Work Phone #
Email Address
Relationship
20
Additional Contact Information 2:
Full Name
Address
Home Phone #
Cell Phone #
Work Phone #
Email Address
Relationship
21
Advanced Directives
Financial P.O.A.
Home Phone #
Work Phone #
Cell Phone #
Durable P.O.A. for Healthcare
Home Phone #
Work Phone #
Cell Phone #
22
Living Will?* This field is required.
YESNO
23
Advanced Directives Continued..
Religion Preference
Church
Clergy
Clergy Phone #
Attending Physician
Physician Phone #
Address
24
Advanced Directives Continued..
Dentist
Dentist Phone #
Dentist Address
Eye Doctor
Eye Doctor Phone #
Eye Doctor Address
25
Advanced Directives Continued..
Podiatrist
Podiatrist Phone #
Podiatrist Address
Pharmacy
Pharmacy Phone #
Pharmacy Address
26
Advanced Directives Continued..
Hospital Preference
Hospital Phone #
Hospital Address
Mortuary
Mortuary Phone #
Mortuary Address
27
Assets* This field is required.
Checking Account Balance
Savings Account Balance
Investments/CD's
Stocks/Bonds
Realestate
Other
Total Assets
28
Monthly Income* This field is required.
Social Security
Pension/Retirement
Rental Income
Investment Income
Other
Total Monthly Income
29
Current DiagnosisDescription
Huge
Large
Normal
Small
Ok
Ok
30
History/Past DiagnosisDescription
Huge
Large
Normal
Small
Ok
Ok
31
Current Medications
Medication
Dose
Time(s)
32
Current Medications
Medication
Dose
Time(s)
33
Current Medications
Medication
Dose
Time(s)
34
Current Medications
Medication
Dose
Time(s)
35
Current Medications
Medication
Dose
Time(s)
36
Current Medications
Medication
Dose
Time(s)
37
Food/Drug Allergies
38
Condition of Sight* This field is required.
Good
Fair
Poor
39
Condition of Hearing* This field is required.
Good
Fair
Poor
40
Check all that apply to current physical status:
Mentally Alert
Forgetful
Confused
Continent of Bladder
Continent of Bowels
Bed-Ridden
Chair-Ridden
Ambulatory
Walks with Assistance
Feeds Self
Requires Help with Feeding
Special Diet
Had one or more falls within last 30 days
Had one or more falls within last 30-180 days
41
Has the applicant been living alone?* This field is required.
YESNO
42
If yes, for how long?* This field is required.
43
During the past five years has the applicant
Had a prior stay at this facility?
Had a stay in another nursing home?
Had a stay in another residential facility, board and care home, or assisted living facility?
Had a stay in a group home?
Had a stay in a mental health facility (psychiatric setting)?
44
What is the highest level of education the applicant has achieved?* This field is required.
No Schooling
8th grade or less
Some High School
High School Graduate
Technical or Trade School
Some College
Bachelor's Degree
Graduate Degree
45
Does the applicant have a history of mental illness, intellectual disability, or developmental disability?* This field is required.
YESNO
46
What are the applicant's likes/dislikes,habits? (Check all that apply)
Stays up late (after 9:00 p.m.)
Naps during the day
Goes out one or more days per week
Keeps busy with hobbies, reading, or fixed daily routine
Spends most of time alone or watching TV
Uses tobacco products
Has distinct food preferences
Eats between meals
Uses alcoholic beverages at least weekly
Wakens to toilets during the night
Pefers Showers
Pefers Baths
Prefers a.m. shower/bath
Prefers p.m. shower/bath
Has daily contact with relative and/or friends
Usually attends Church, Temple, or Synagogue
FInds strength in faith
Involved in group activites
47
Signature* This field is required.I declare that the above statements are true and accurate to the best of my knowledge.
Clear
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