RESIDENT'S PROFILE 

YOUR CONTACT INFORMATION

* Required field
Name: *
Address: *
City: *
State: *
Zip: *
Day Time Phone: *
Night Time Phone: *
Best Time To Call: *
E-mail: *

YOUR SENIOR OR ADULT INFORMATION
Name:
Age:
Gender: Male    Female
Presently Living Arrangement:



If Living In A Facility, What Is The Name? 

City:
State:
EXPECTED DATE OF PLACEMENT: 

 
CITY OF CHOICE TO MOVE: 
COUNTY:  
STATE OF CHOICE:  
ZIP CODE: 
TYPE OF FACILITY YOU ARE LOOKING FOR: (please check all that apply)
Independent Living or Retirement Homes
Assisted Living Facilities
Residential Care Facility for Elderly (RCFE)
Nursing Care or Skilled Nursing Facilities (SNF)
Alzheimer’s/Dementia Care
Home Health Care
Continuing Care Retirement Communities (CCRC)
Adult Residential Facility (ARF)
 
Room Type:

Monthly Budget:

 
Please check all types of care needed
Agitated, Combative, Confused, Wanderer Bedridden Blind
Colostomy Deaf Dementia
Diabetic with Insulin Hospice Incontinent Bowel and Bladder
Indwelling catheter Needs to have Nurse on duty or on call Obese
Oxygen Needs transportation to the doctor Smoker
Wheelchair/Walker/Cane With pets

Wound care

Alzheimer's Tracheotomy Ventilator


HEALTH ISSUES (Please check all that apply)

Alzheimer’s Disease Mental Retardation
Bipolar Disorder Obesity
Cancer Paralysis
Cerebral Palsy Parkinson's Disease
Dementia Pulmonary Disease (Lung problems)
Depression Schizophrenia
Diabetic Type 1 (needs injection) Spina Bifida
Diabetic Type 2 (controlled by diet and pills) Stroke
Epilepsy Other
Heart Disease No Health Issues
Macular Degeneration    

DOES THIS PERSON REQUIRES 24 HOUR CARE?     YES    NO

DOES THIS PERSON REQUIRES HOSPICE CARE?    YES    NO

PLEASE list other health issues that are relevant to your senior, adult or loved ones so that we may able to assist you better:  

    

 

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