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Please Complete All Sections

Name of Inquirer(s):*
Inquirer's Phone#:*
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Inquirer's E-mail:*
Inquirer's Address:*
Inquirer's Relationship to Senior:*
Senior's Name:*
Age:*
Gender:*
Ethnicity:
Senior Housing Type Desired:*
Zip Codes requesting placement in:*
Time Frame to Move:*
Current Living Situation:*
Name of Hospital/Rehab (if applicable)
Room#:
Name of Assigned Social Worker/Case Manager & Phone #:
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Is Senior a Veteran or Spouse of Veteran:
If Yes, Has Application for VA Aid & Attendance been Submitted:
Approximate Monthly Budget for Care:
Check all Chronic Illness(s):
Medical Comments:
Approximate # of Medications per day
Has Senior been diagnosed with Dementia?
What kind?
Date of Diagnosis:
Mobility:
Fall Risk?
Mobility Comments:
Use of Stairs:
Use of Stairs Comments:
Continence / Toileting:
Continence / Toileting Comments:
Bathing:
Bathing Comments:
Grooming:
Grooming Comments:
Dressing:
Dressing Comments:

Behaviors

1) Withdrawn / Keeps to themselves:
2) Depressed:

3) Wanders

• Moving without purpose:
• Looks for former home:
• Actively tries to leave home
• Wanders during day:
• Wanders during evening/night:
Comments about wandering:

4) Sleep Disturbance

• Unable to sleep/agitated at night:
• Frequently sleeps during the day:
Comments about sleep:

5) Verbally Inappropriate

• Uses foul language:
• Sounds angry and threatening:
Comments about Verbally Inappropriate:

6) Disruptive Behaviors

• Yells:
• Demands Attention:
• Takes others possessions:
• Inappropriate Public Behavior (Disrobes/Urinates):
Comments about Disruptive Behaviors:

7) Combative Behaviors

• Throws objects:
• Strikes out, Kicks or Punches:
• Pinches, bites, spits, scratches, pulls hair:
Comments about Combative behaviors:

8) Resistant Behaviors 

• Refuses to wash:
• Refuses to eat:
• Refuses to drink:
• Refuses to care for self:
• Refuses to allow others to help:
• Refuses Medicines:
• Refuses to comply to safety advice:
Comments about Resistant Behaviors :

9) Communication

• Expresses needs, ideas, wants:
• Unwilling to communicate needs:
• Unable to communicate:
Comments about communication:

10) Eating patterns

• Eats full scheduled Meals / good appetite:
• Eats sometimes, but still maintains weight:
• Eats only when they want:
Comments about Eating:

Have you called other placement services?:
Who?
Have you contacted or toured any communities?
Where?

Senior Care Lifestyles, LLC is the sole owner of the information collected on this site. We will not sell this information, or share this information with any third party entity. This information is considered confidential and is used in the search for communities and senior housing options that meet the client’s medical needs, personal care, and budget.

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