Inquiry form

2. 

3. Inquiry form for placement at Portage Manor (Form 2a)

5. Name of Inquirer:*

7. Relationship to Prospective Resident:

8. Phone #:

12. Prospective Resident:*

13. D.O.B.*

14. Age: *

16. Gender: *

17. Where have they been Living?*

19. How did they hear about Portage Manor?*
    -- Select One --FriendNewsDoctorOther

20. What is their Diagnosis?*

22. Primary Care Doctor: *

23. Phone #: *

25. Specialist/Psychiatrist: *

26. Phone #: *

30. Financial Information
    Please check YES or NO to the following questions

    Please check YES or NO to the following questions

32. SSD*

    1. YES
    2. No

33. If Yes, the Amount $:

34. Medicare *

    1. YES
    2. NO

35. If Yes, the Policy Number #:

37. SSI*

    1. YES
    2. NO

38. If Yes, the Amount $:

39. Medicaid*

    1. YES
    2. NO

40. If Yes, the Policy Number #:

42. VA*

    1. YES
    2. NO

43. If Yes, the Amount $:

45. Vechicle*

    1. YES
    2. NO

46. If Yes, the Year, Make, Model, & Estimated Value:

48. Home*

    1. YES
    2. NO

49. If Yes, the Address & Estimated Value:

51. Property*

    1. YES
    2. NO

52. If Yes, the Type, Location, & Estimated Value:

54. Burial Insurance*

    1. YES
    2. NO

55. If Yes, Company Name:

57. Health Insurance*

    1. YES
    2. NO

58. If Yes, Company Name:

60. Life Insurance*

    1. YES
    2. NO

61. If Yes, Company Name:

63. Checking Account*

    1. YES
    2. NO

64. Savings Account*

    1. YES
    2. NO

65. If Yes, Bank Name & Account Number(s):

69. Medical Information
    Please check YES or NO to the following questions

    Please check YES or NO to the following questions

71. 1. Is there any history or evidence that the individual exhibits behavior that might present a danger to other residents, staff, and/or themselves?*

    1. YES
    2. NO

73. 2. Does the individual have a documented diagnosis of intellectual disability, developmental delay, and/or other related conditions? *

    1. YES
    2. NO

75. 3. Do they require assistance to ambulate? *

    1. YES
    2. NO

77. 4. Do they dress themselves independently? *

    1. YES
    2. NO

79. 5. Do they feed themselves independently and are able to chew and swallow without difficulty?*

    1. YES
    2. NO

81. 6. Do they bathe themselves independently? *

    1. YES
    2. NO

83. 7. Are they alert and oriented? *

    1. YES
    2. NO

85. 8. Are they forgetful? *

    1. YES
    2. NO

87. 9. Do they wander? *

    1. YES
    2. NO

89. 10. Are they continent of bladder and bowel?*

    1. YES
    2. NO

91. 11. Do they have special diet needs?*

    1. YES
    2. NO

92. If Yes, what are they?

96. What are your expectations for living at Portage Manor?*

100. Internal Staff Only

102. Inquiry Date
     Inquiry Date

103. Reviewed by:

104. Entered in EMR:

Leave This Blank:


106. 1. Receive an email copy of this form.
107. Email address

     This field is not part of the form submission.

108. Submit Submit and Print

* indicates a required field