APPENDIX
D
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SAMPLE
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Forms
For Day Care in Long-Term Care Facilities
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FORM
A:
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APPLICATION
FOR DAY CARE
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NAME
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AGE
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BIRTH DATE
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ADDRESS
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PHONE
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SOCIAL SECURITY NUMBER
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MEDICARE NUMBER
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WITH WHOM DO YOU LIVE?
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RELATIONSHIP?
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PERSON TO CONTACT IN AN
EMERGENCY
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ADDRESS
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PHONE
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BUSINESS PHONE
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PHYSICAL LIMITATIONS (please
list)
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1.
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2.
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3.
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4.
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SPECIAL PHYSICAL NEEDS
(medications during day, special rest periods, etc. please list)
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1.
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4.
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2.
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5.
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3.
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6.
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MEDICAL PROBLEMS (circle)
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1.
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diabetic
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8.
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hearing
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2.
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subject to seizures
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9.
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eyesight
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3.
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heart disease
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10.
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assistance with meals
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4.
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dizziness
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11.
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any paralysis
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5.
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urinary control problem
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12.
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difficulty in walking
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6.
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bowel control problem
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13.
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periodic confusion
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7.
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special diet
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14.
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allergies (list)
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15.
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others
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ARE YOU PRESENTLY UNDER A DOCTOR'S
CARE?
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NAME AND ADDRESS OF PHYSICIANS
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SPECIAL INTEREST OR HOBBIES
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DAYS ENTERED IN PROGRAMMING
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A.M.
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P.M.
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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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DO YOU HAVE TRANSPORTATION?
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