Full Name *
Current Address (required) ---AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & DepsArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepChadChileChinaColombiaComorosCongoCongo {Democratic Rep}Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIreland {Republic}IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar, {Burma}NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSt Kitts & NevisSt LuciaSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe
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
Occupation(s):
Clubs, Organizations and Memberships
Doctor's Name:
Phone Number:
Address: ---AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & DepsArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepChadChileChinaColombiaComorosCongoCongo {Democratic Rep}Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIreland {Republic}IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar, {Burma}NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSt Kitts & NevisSt LuciaSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe
Dentist's Name:
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:
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
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
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
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
Power Of Attorney YesNo
Durable Power Of Attorney YesNo
A Living Will YesNo
Resuscitation Directives Yesno
List Any Person, Agency Or Organization Responsible For Payments Of The Resident
List Any Special Directions
Insurance Company
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).
Braley Care Homes6192 US 60Hurricane, WV 25526
Fax: (304) 201-3678
Email: chris@braleycarehomes.com