Nursing Home Intake Form

DATE:

WARD/DECEDENT'S NAME:

ALSO/KNOWN/AS:

DOB:

DOD:

AGE:

SSN:

WARD/DECEDENT'S CURRENT/LAST ADDRESS:

COUNTY OF RESIDENCE:

PROBATE

PLACE OF DEATH:

WILL OR INTESTATE:

DATE OF WILL:

LOCATION OR ORIGINAL WILL:

PERSONAL REPRESENTATIVE & ADDRESS:

PHONE NO.:

WORK NO.:

If Testate list all beneficiaries, if in testate list all heirs in the following order: spouse & all natural and adopted children-if any child deceased, list name and all deceased child's children. If no spouse or children, list siblings then nephews/nieces, then cousins.
NAME ADDRESS PHONE RELATIONSHIP

1.
2.
3.
4.
5.

GUARDIANSHIP

REASON FOR INCAPACITY:

SUGGESTED GUARDIAN AND ADDRESS:

PHONE NO.:

WORK NO.:

LIST ANY ASSETS:

NURSING HOME INTERVIEW SHEET

RESIDENT:

INTERVIEWEE:

INTERVIEWEE'S ADDRESS:

HOME PHONE:

WORK NO.:

RELATIONSHIP TO RESIDENT:

RESIDENT'S D.O.B.:

D.O.D.:

SS#:

DEFENDANT NURSING HOME/ADDRESS:

REASON FOR NH ADMIT:

ATTENDING PHYSICIAN:

DATE ENTERED:

DATE LEFT:

APPROXIMATE DATE YOU FEEL THE ABUSE BEGAN:

DATE WRONGFUL DEATH STATUTE RUNS (IF, APPLICABLE):

DEPRIVATIONS OF RIGHTS

PRESSURE ULCERS-SKIN TEARS/LOCATION:

DROPS/FALLS/FRACTURES/BRUISES:

MALNUTRITION/DEHYDRATION:

MEDICATION ERRORS/INFECTIONS:

SERVICES DENIED/HYGIENE/RESTRAINTS/OTHER:

RESIDENT ABILITIES

Prior to admit = 1, During residency = 2, Post residency = 3

SELF-FEEDING:

WALKING:

SITTING ALONE:

ABLE TO MAKE NEEDS KNOWN:

UNDERSTANDS:

MEDICAL CONDITIONS:

HEART:
CANCER:
DIABETES:
ALZHEIMER'S:
OTHER:

HEALTH CARE PROVIDERS/ADDRESSES

PRIOR TO NURSING HOME ADMISSION:

DURING NURSING HOME STAY:

AFTER DISCHARGE FROM NURSING HOME:

HEALTH INSURANCE BENEFITS PROVIDED

MEDICARE: YES   NO   MEDICARE NO.:
MEDICAID: YES   NO   MEDICAID NO.:
HMO/HEALTH YES   NO   POLICY NO.:

CARRIER: :

MISC.

EXISTING PHOTOGRAPHS: YES   NO   LOCATION:

OTHER:

NEW PHOTOGRAPHS: YES   NO
IF YES, BY WHOM:
WHEN:

CORP. INFO: ORDER:

POLICE REPORTS: ORDER:

HRS LICENSING: ORDER:

INSURANCE DSCL. ORDER:

AUTOPSY DONE: YES   NO   IF YES, ORDER:

NOTES: