Thank you for your inquiry. To get the most out of our time together it would be helpful if you would fill out this longer form to the best of your ability and submit
Confidential Senior Information Form
Please complete this form to the best of your ability. This will help us be more prepared for our assessment meeting so we can both get more out of our time together. All information provided is confidential.
If you have any questions please call us directly at: 480-654-8919 or 800-910-3590
Information about the senior & their caregiver
Senior's Name:
Address:
City State Zip Code
Phone: e-Mail Date of Birth:
Marital Situation: Married Divorced Widowed
Height: Weight:
Primary care giver now:
Caregiver's address:
Caregiver's phone number:
Caregiver's e-mail:
Please describe what is prompting you to explore assisted living at this time:
Please indicate below what is your senior's diagnosis: (Check all that all that apply.)
Congestive heart failure
Cancer
Parkinson's
Bi-polar disease
Depression
Alzheimer's disease
High blood pressure
Arthritis
Dementia (memory loss)
Forgetfulness
Diabetes, insulin dependent
Emphysema
Incontinent
Alcoholic
Other
On a scale of 1-10 with 10 being excellent and 1 being very challenged, how would you rate your seniors ability in the following areas? Please circle your best estimation
Hearing: 1 2 3 4 5 6 7 8 9 10 Comments:
Speech: 1 2 3 4 5 6 7 8 9 10 Comments:
Vision: 1 2 3 4 5 6 7 8 9 10 Comments:
Balance: 1 2 3 4 5 6 7 8 9 10 Comments:
Mobility: 1 2 3 4 5 6 7 8 9 10 Comments:
Mental: 1 2 3 4 5 6 7 8 9 10 Comments:
Attitude: 1 2 3 4 5 6 7 8 9 10 Comments:
Continence: 1 2 3 4 5 6 7 8 9 10 Comments:
Please describe their night time needs/behavior:
Describe any special diet needs or behaviors:
Smoker: Yes No
Pets/Animals: Owns Animals? Allergic to Animals?
Preferred type of facility: Large Small Private Room Semi-private Room
Medicaid eligible: (ALTCS in AZ) Yes No
Veteran: Yes No
Preferred location of facility:
Time frame for moving to facility:
Who has Power of Attorney?
