APPENDIX D

SAMPLE

Forms For Day Care in Long-Term Care Facilities

FORM A:

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?

SAMPLE

FORM B:

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