Resident Application Form

    General Information

     

    Full Name *

    Current Address (required)




    Date of Birth

    Place of Birth

    Marital Status

    Spouse's Name

    Number of Living Children

    Religious Affiliation

    Name and Address of Church

    Pastor Phone Number:

    Church Phone Number:

    Hobbies and Interests

     


     

    History

     

    Occupation(s):

    Clubs, Organizations and Memberships

     


     

    Present Physicians

     

    Doctor's Name:

    Phone Number:

    Address:




    Dentist's Name:

    Address:




    Phone Number:

    Is The Applicant Scheduled For Any Future Doctor's Appointments That The Braley Care Staff Should Be Aware Of?
    YesNo

    If Yes, Please Name The Physician(s), Along With The Date And Time Of Appointment:

     


     

    Medical Information

     

    Known Allergies

    Is The Applicant Confined In A Hospital Or Nursing Home?
    YesNo

    If Yes, What Is The Name And Address Of The Facility?

    For What Reason(s)?

    List Of Current Medications

     


     

    Present Physical Condition

     

    Applicant's Present Diagnoses

    Primary

    Secondary

    Has There Been A Drastic Weight Loss?
    YesNo

     

    Does The Applicant Have Dentures?
    UpperLowerFull

     

    Control Of Bowels?
    YesNo

     

    Control Of Bladder?
    YesNo
     

    Does The Applicant Have Any Self-Managing Colostomies, Urostomies, Or Catheters?
    YesNo

     

    Frequent Diarrhea?
    YesNo

     

    Frequent Constipation?
    YesNo

     

    Is There Any Other Medical Or Health Information Braley Care Homes Should Know About This Applicant?

    Is The Resident "CODE" Or "NO CODE"?
    CODENO CODEUnsure

     


     

    Psychological Information

     

    Is The Applicant Generally Able To Communicate Clearly?
    YesNo

     

    Is The Applicant Generally Alert Or Confused?
    AlertConfused

     

    How Does The Applicant Feel About Receiving In-Home Service?

    How Does The Applicant Spend Their Time?

    The Applicant Seems (check all that apply)
    DepressedAngryCheerfulFearfulContentConfusedCombativeWonders

     


     

    Other Information

     

    Each resident shall have a written, signed and dated health assessment by a physician or other licensed health care professional, authorized under the state law to perform this assessment, not more then sixty (60) days prior to the residents admission, or no more than five (5) working days following admission, and at least annually after that. The admission and annual health assessment shall include screening for tuberculosis and other communicable diseases if indicated by exposure, prevalence or risk according to current medial practice in congregate living situations as indicated by the secretary.

     

    Responsible Parties To Be Notified In Case Of Emergency, Discharge Or Demise Of The Resident:

     

    NAME

    Relationship

    Address

    Phone Number

    Does The Applicant Have Legal Representation?
    YesNo
     
     

    Check If Applicant Has Any Of The Following:


     

    A Guardian

    YesNo

    If Yes, Give Name, Address And Phone Number

    Medical Power Of Attorney
    YesNo

    If Yes, Give Name, Address And Phone Number

    Power Of Attorney
    YesNo

    If Yes, Give Name, Address And Phone Number

    Durable Power Of Attorney
    YesNo

    If Yes, Give Name, Address And Phone Number

    A Living Will
    YesNo

     

    Resuscitation Directives
    Yesno

    List Any Person, Agency Or Organization Responsible For Payments Of The Resident

    List Any Special Directions

     


     

    Insurance Information

     

    Insurance Company

    Address:




    Policy #

    Group #

    Payor #

     
     
    * Please note that Braley Care Homes will ask for copies of the applicant's insurance cards, Social Security card, MPOA, POA, Living Will and DNR (if applicable).
     
     

      General Information

       

      Full Name *

      Current Address (required)




      Date of Birth

      Place of Birth

      Marital Status

      Spouse's Name

      Number of Living Children

      Religious Affiliation

      Name and Address of Church

      Pastor Phone Number:

      Church Phone Number:

      Hobbies and Interests

       


       

      History

       

      Occupation(s):

      Clubs, Organizations and Memberships

       


       

      Present Physicians

       

      Doctor's Name:

      Phone Number:

      Address:




      Dentist's Name:

      Address:




      Phone Number:

      Is The Applicant Scheduled For Any Future Doctor's Appointments That The Braley Care Staff Should Be Aware Of?
      YesNo

      If Yes, Please Name The Physician(s), Along With The Date And Time Of Appointment:

       


       

      Medical Information

       

      Known Allergies

      Is The Applicant Confined In A Hospital Or Nursing Home?
      YesNo

      If Yes, What Is The Name And Address Of The Facility?

      For What Reason(s)?

      List Of Current Medications

       


       

      Present Physical Condition

       

      Applicant's Present Diagnoses

      Primary

      Secondary

      Has There Been A Drastic Weight Loss?
      YesNo

       

      Does The Applicant Have Dentures?
      UpperLowerFull

       

      Control Of Bowels?
      YesNo

       

      Control Of Bladder?
      YesNo
       

      Does The Applicant Have Any Self-Managing Colostomies, Urostomies, Or Catheters?
      YesNo

       

      Frequent Diarrhea?
      YesNo

       

      Frequent Constipation?
      YesNo

       

      Is There Any Other Medical Or Health Information Braley Care Homes Should Know About This Applicant?

      Is The Resident "CODE" Or "NO CODE"?
      CODENO CODEUnsure

       


       

      Psychological Information

       

      Is The Applicant Generally Able To Communicate Clearly?
      YesNo

       

      Is The Applicant Generally Alert Or Confused?
      AlertConfused

       

      How Does The Applicant Feel About Receiving In-Home Service?

      How Does The Applicant Spend Their Time?

      The Applicant Seems (check all that apply)
      DepressedAngryCheerfulFearfulContentConfusedCombativeWonders

       


       

      Other Information

       

      Each resident shall have a written, signed and dated health assessment by a physician or other licensed health care professional, authorized under the state law to perform this assessment, not more then sixty (60) days prior to the residents admission, or no more than five (5) working days following admission, and at least annually after that. The admission and annual health assessment shall include screening for tuberculosis and other communicable diseases if indicated by exposure, prevalence or risk according to current medial practice in congregate living situations as indicated by the secretary.

       

      Responsible Parties To Be Notified In Case Of Emergency, Discharge Or Demise Of The Resident:

       

      NAME

      Relationship

      Address

      Phone Number

      Does The Applicant Have Legal Representation?
      YesNo
       
       

      Check If Applicant Has Any Of The Following:


       

      A Guardian

      YesNo

      If Yes, Give Name, Address And Phone Number

      Medical Power Of Attorney
      YesNo

      If Yes, Give Name, Address And Phone Number

      Power Of Attorney
      YesNo

      If Yes, Give Name, Address And Phone Number

      Durable Power Of Attorney
      YesNo

      If Yes, Give Name, Address And Phone Number

      A Living Will
      YesNo

       

      Resuscitation Directives
      Yesno

      List Any Person, Agency Or Organization Responsible For Payments Of The Resident

      List Any Special Directions

       


       

      Insurance Information

       

      Insurance Company

      Address:




      Policy #

      Group #

      Payor #

       
       
      * Please note that Braley Care Homes will ask for copies of the applicant's insurance cards, Social Security card, MPOA, POA, Living Will and DNR (if applicable).
       
       

      You can print and mail or fax the forms to our office at:

      Braley Care Homes
      6192 US 60
      Hurricane, WV 25526

      Fax: (304) 201-3678

      Email: chris@braleycarehomes.com