77 Ill. Adm. Code 300.APPENDIX D
D Forms for Day Care in Long-Term Care Facilities
Section 300.APPENDIX D Â Â Forms
for Day Care in Long-Term Care Facilities
SAMPLE
APPLICATION
FOR DAY CARE
FORM A
NAME
AGE
BIRTH DATE
ADDRESS
PHONE
SOCIAL SECURITY NUMBER
MEDICARE NUMBER
WITH WHOM DO YOU LIVE?
RELATIONSHIP?
PERSON TO CONTACT IN AN
EMERGENCY
ADDRESS
PHONE
BUSINESS
PHONE
PHYSICAL LIMITATIONS (please
list)
1.
2.
3.
4.
SPECIAL PHYSICAL NEEDSÂ
(medications during day, special rest periods, etc. please list)
1.
4.
2.
5.
3.
6.
MEDICAL PROBLEMS (circle)
1.
diabetic
8.
hearing
2.
subject to seizures
9.
eyesight
3.
heart disease
10.
assistance with meals
4.
dizziness
11.
any paralysis
5.
urinary control problem
12.
difficulty in walking
6.
bowel control problem
13.
periodic confusion
7.
special diet
14.
allergies (list)
15.
others
ARE YOU PRESENTLY UNDER A
DOCTOR'S CARE?
NAME AND ADDRESS OF PHYSICIANS
SPECIAL INTEREST OR HOBBIES
DAYS ENTERED IN PROGRAMMING
A.M.
P.M
Monday
Tuesday
Wednesday
Thursday
Friday
DOYOU HAVE TRANSPORTATION?
(Source added
at 9 Ill. Reg. 11049, effective July 1, 1985)
FORM B
SAMPLE
PHYSICIAN
PERMISSION FORM
has applied for admittance to
the day care program at
. Please
supply the following information and also give written
permission for
to participate in the activity
program.
Physical
Limitations
Degree of
activity
Can day care resident be involved
in activities outside of the facility
(in the community)?
Has
been evaluated within the last
30 days
and found to be free of
communicable and infectious disease?
Medications and/or treatments
and diet needed by day care resident during
the period of time spent in
the facility.
Can day care resident take own
medication?
Allergies
Date:
Signature
of Physician: