B Forms for Day Care in Long-Term Care Facilities

Section 390 Section 390.APPENDIX B  Forms for Day Care in Long-Term Care Facilities APPENDIX B Form A Sample Forms for Day Care in Long-Term Care Facilities APPLICATION FOR DAY CARE 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 NEEDS (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 DO YOU HAVE TRANSPORTATION? 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