Teakwood Coves Assisted Living Pre-Admission Screening
Demographics
Prospective Resident Name
*
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Suffix
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Last 4 digits of Social Security Number
*
Phone Number
*
Please enter a valid phone number.
Gender
*
Please Select
Male
Female
Assigned at Birth
Pronouns
*
Please Select
She/Her/Hers
Him/He/His
Them/They/Theirs
Primary Language
*
Email
*
example@example.com
Do you own any pets/ animals?
*
Please Select
Yes
No
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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What Medical Needs Do You Have?
Do you have a Primary Care Provider?
*
Please Select
No
Yes
Do you see a specialist?
*
Please Select
No
Yes
Current Diagnosis / Medical Conditions
Are you currently taking any medication?
*
Please Select
Yes - Prescription and/or OTC Only
No
Yes - Over-the-counter (OTC) Only
Have you been diagnosed with Alzheimer's or Dementia?
*
Please Select
What will you need assistance with?
*
Bathing
Eating
Getting in or out of Bed/ Wheelchair
Getting Dressed
Grooming (shaving, hair, make-up, etc)
Incontinence
Toileting
Do you have use anything listed below?
*
Wheelchair
Walker/ Cane/ Rollator
PEG- Tube
Catheter
Colostomy bag
IV antibiotics
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Current or past psychiatric care?
*
Please Select
Yes
No
Do you have any issues with swallowing/choking?
*
Please Select
Dietary or Fluid Restrictions
*
Please Select
Yes
No
Do you get more than 5 hours of uninterrupted sleep most nights?
*
Please Select
Yes
No
How soon are you looking to move?
*
Please Select
Immediately
Within 1-2 weeks
Within 4 weeks
Not Sure
Just Looking
Have you lived in Assisted Living before?
*
Please Select
Yes
No
What is the best time of day to contact you?
*
Please Select
Morning (8:00am- 11:59am)
Noon (12:00pm-3:59pm)
Evening (4:00pm- 8:00pm)
How should we contact you
*
Please Select
Phone Call
Email
Please list any concerns that you would like us to be aware of below:
File Upload: Please upload any documents that may expedite your admission process - Most recent doctors visit notes, medication list, POA documents, etc.
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