• EVERGREEN

    EVERGREEN

  • Tel: +27 21 702 3200/2 Email: info@evergreenlifestyle.co.za Physical: Amdec House, Silverwood Close, Steenberg Office Park, Tokai, 7945 Postal: PO Box 30487, Tokai, 7966, South Africa Web: www.evergreenlifestyle.co.za

    Please complete your biographical data below and give us an accurate indication of various aspects of your health information and daily functionality on the second page. Please report any recent changes in your health status; such as new diagnoses, recent surgeries, etc. Assist your partner/spouse to complete the document as required. Any health data will be handled with strict confidentiality as per policy parameters.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • MEDICAL INFORMATION

  • Preferred Hospital: Medical History/Chronic conditions: Recent changes in your health statusDescribe: such as new diagnoses, recent surgeries or procedures. Allergies/Special Alerts: Medication:

  • Specialist Doctor: Pharmacy: Religion: Living Will: Yes/No Preferred funeral company:

  • NEXT OF KIN

  • Evergreen Health (Pty) Ltd I Reg No. 2018/041239/07 Directors: JE Porter, G Reed, B Steyn

  • Image field 43

  • EVERGREEN

  • Tel: +27 21 702 3200/2 Email: info@evergreenlifestyle.co.za Physical: Amdec House, Silverwood Close, Steenberg Office Park, Tokai, 7945 Postal: PO Box 30487, Tokai, 7966, South Africa Web: www.evergreenlifestyle.co.za

    RESIDENT ASSESSMENT-PLEASE TICK OFF THE MOST RELEVANT DESCRIPTION OF YOURSELF

    1. Mobility Can move independently, with or without appliances Require partial support or supervision Require full assistance Bedridden and totally dependent

  • 2. Personal Hygiene Independent Require supervision or assistance Totally dependent

  • 3. Eating and Drinking Independent Require supervision or assistance Must be fed

  • 4. Dressing Independent Require supervision or assistance Totally dependent

  • Satisfactory with glasses Impaired, require assistance Blind, fully dependent

  • 6. Hearing Satisfactory Impaired, require hearing aids Deaf, fully dependent

  • Can takes medication independently Require assistance

  • 9. Therapeutic Activities Independently participate in activities Require assistance

  • Good memory and orientation Require support and supervision

  • Require dressing or other special care

  • Evergreen Health (Pty) Ltd I Reg No. 2018/041239/07 Directors: JE Porter, G Reed, B Steyn

  • Image field 87

  • EVERGREEN

  • Tel: +27 21 702 3200/2 Email: info@evergreenlifestyle.co.za Physical: Amdec House, Silverwood Close, Steenberg Office Park, Tokai, 7945 Postal: PO Box 30487, Tokai, 7966, South Africa Web: www.evergreenlifestyle.co.za

    No caregiver required Requires some support or continuous assistance

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Evergreen Health (Pty) Ltd I Reg No. 2018/041239/07 Directors: JE Porter, G Reed, B Steyn

  • Image field 97

  • EVERGREEN

  • Tel: +27 21 702 3200/2 Email: info@evergreenlifestyle.co.za Physical: Amdec House, Silverwood Close, Steenberg Office Park, Tokai, 7945 Postal: PO Box 30487, Tokai, 7966, South Africa Web: www.evergreenlifestyle.co.za.

    Evergreen Health (Pty) Ltd I Reg No. 2018/041239/07 Directors: JE Porter, G Reed, B Steyn

  •  
  • Should be Empty: