Resident Info And Assessment

Resident Information Personal Information Resident Name ________________________ Prefers to be called ________________________ Age ________ DOB ____________________ SS# ____________________________________ Marital Status _________________________ Spouse name _____________________________ Previous Address _______________________________________________________________ Religious preference ___________________ Active / Location __________________________ Responsible Person Name _________________________________________ Relationship ____________________ Address ______________________________________________________________________ Home Phone _______________________ Work Phone _________________________________ Emergency Contacts 1. Family Contact / Name _________________________ Relationship ____________________ Address ______________________________________________________________________ Home Phone _______________________ Work Phone _________________________________ 2. Family Contact / Name _________________________ Relationship ___________________ Address ______________________________________________________________________ Home Phone _______________________ Work Phone _________________________________ 3. Primary Physician / Name _____________________________________________________ Address ______________________________________________________________________ Office Phone ______________________ Emergency Phone _____________________________ 4. Other Physician (Specialist) / Name ______________________________________________ Address ______________________________________________________________________ Office Phone ______________________ Emergency Phone _____________________________ 5. Dentist / Name _________________________ Office Phone __________________________ 6. Hospital of Choice ______________________ Phone # ______________________________ 7. Attorney ______________________________ Phone # ______________________________ 8. Pharmacy _____________________________ Phone # ______________________________ 9. Mortuary ______________________________ Phone # _____________________________

Insurance Information Resident Name _____________________________________ Room number _________ Insurance information may be required for laboratory work, physician/podiatry visits, pharmacy orders, or other arising situations. Please complete all appropriate insurance information. Medicare number ___________________________ Medicaid number ___________________________ Name of insurance company ________________________________________________ Name of insurance carrier __________________________________________________ Insurance company address ________________________________________________ Insurance company phone number ___________________________________________ Is your medication insurance information/coverage different from the above information? Yes ____

No ____

If yes, please provide the following information: Name of insurance company ________________________________________________ Name of insurance carrier __________________________________________________ Insurance company address ________________________________________________ Insurance company phone number ___________________________________________ Do you have long term care insurance? Yes ____

No ____

If yes, please provide the following information: Name of insurance company ________________________________________________ Name of insurance carrier __________________________________________________ Insurance company address ________________________________________________ Insurance company phone number ___________________________________________ *Please include copies of all appropriate Medicare, Medicaid and other insurance cards. The Inn on Barton Creek Assisted Living will not be responsible if inadequate insurance information is provided.

Medical History Background Information Recent hospitalization _______ Dates __________________ Reason ______________________ Diagnosis / conditions ___________________________________________________________ _____________________________________________________________________________ _ Other hospitalizations / reason _____________________________________________________ Allergies to medications or food ___________________________________________________ Do you have a Living Will? ___ Medical Treatment Plan? ___ Special Power of Attorney? ____ Medications List all prescriptions currently taken or used on an occasional basis: 1. ___________________________________________________________________________ 2. ___________________________________________________________________________ 3. ____________________________________________________________________________ 4. ____________________________________________________________________________ 5. ____________________________________________________________________________ 6. ____________________________________________________________________________ 7. ____________________________________________________________________________ 8. ____________________________________________________________________________ 9. ____________________________________________________________________________ 10. ___________________________________________________________________________

List all over the counter medications taken on a routine or occasional basis: 1. ____________________________________________________________________________ 2. ____________________________________________________________________________ 3. ____________________________________________________________________________ 4. ____________________________________________________________________________ 5. ____________________________________________________________________________ 6. ____________________________________________________________________________ 7. ____________________________________________________________________________ Level of Functioning 1. Activities of Daily Living: Rate as I = independent A = needs assistance D = Dependent Eating _____________________________

Bathing ___________________________

Dressing / Grooming _________________

Toileting __________________________

Ambulation _________________________

Transfers _________________________

Escorts to meals _____________________

Other _____________________________

2. Instrumental ADL’s: Rate as I = independent A = needs assistance D = Dependent Personal laundry _________________

Light Housekeeping __________________

Handling money _________________

Using the phone _____________________

Preparing light meals _____________

Managing medications ________________

3. Appliances: Please circle and/or list any equipment or aids: Cane / Walker / Wheel chair _______

Braces or prosthesis ___________________

Bed side commode _______________

Oxygen _____________________________

Other ___________________________________________________________________

Communication Deficits 1. Do you have trouble with your vision? _____ Please describe_________________________ Glasses _____ Contacts _____ Glaucoma _____ Macular Degeneration _____ 2. Do you have trouble communication your needs? _____ Please describe _________________ Primary language ______________________ Aphasic _____ Signs _______________________ 3. Do you have trouble understanding others? _____ Please describe ______________________ Deaf _____ Hard of Hearing _____ Confusion _____ Hearing Aide _____ Other ____________ Miscellaneous 1. Who will be taking care of your financial matters including the Inn on Barton Creek bill? _____________________________________________________________________________ _ 2. Would you like every two-hour check during the night? ______________________________ 3. Other information you would like us to have on file __________________________________ _____________________________________________________________________________ _ _________________________________ Name of person completing this form

_____________________ Date: