Pleasant View Rehabilitation and Health Care Center

500 N. Jackson St. Morrison, IL 61270

Phone: 815-772-7288Fax: 815-772-2399

PRE-ADMISSION FORM

Upon completion of this form you will be placed on our waiting list

Date: ______ presently residing at (hospital, nursing home):______

Name: ______(First) (Middle) (Last) (Maiden)

Applicant’s Home Address: ______

Applicant’s Phone Number: ______

Birth Date: ______Age: ______Marital Status: M W S D

Placement: Sheltered Care______Nursing ______Physician: ______

POA/Responsible Party: ______Relationship: ______

Home #: ______Work #: ______Cell #:______

Medical Information/Condition

Diagnosis: ______

Known Allergies: ______

History of Major Surgeries/Medical Conditions: ______

______

Has applicant ever been positive for Tuberculosis: ______

Last Flu Shot Date: ______Last Pneumovax Shot Date: ______

Optometrist: ______Dentist: ______

Hospital Preference: ______Podiatrist: ______

Hearing aids purchased: ______Phone Number: ______

Current Medications: (Continue on back if necessary)

Medications / Dosage / Frequency / Reason

PERSONAL INFORMATION

Eyeglasses: ______Hearing Aid(s): ______Speech Impairment: ______

Special Diet/Restrictions: ______Feeds Self: ______

Dentures: ______Paritals: ______

Recent Weight Loss: ______How Much: ______

Able to dress self: ______What assistance is needed: ______

Bathing preference: Whirlpool: ______Shower: ______

Condition of Skin (rashes, wounds, etc:) ______

Incontinent: Bladder: ______Bowel:______Catheter: ______Ostomy:______

Presently uses: (mark any that apply) Raised Toilet Seat: ______Oxygen: ______

Walker: ______Wheelchair: ______Cane: ______Life Chair: ______

Prone to wander: ______

Prone to become verbally aggressive: ______Prone to become physically aggressive: ______

Please explain: ______

PERSONAL HISTORY

Home address if applicable: ______Military: Y or N

Birthplace: ______Spouse’s Name (Living or Deceased:) ______

Marriage Date: ______Number of Children: ______

______Any Deceased, Name: ______

Mother’s Maiden name : ______Father’s name : ______

Religion: ______Church: ______Clergy : ______

Education: ______Occupations: ______

Past conviction of felony, sex offense or inappropriate sexual behavior: ______

Please explain: ______

Any history of mental illness: ______Please explain: ______

______

DECISIONS

Has the individual participated in the decision to come to this facility: ______

Is there a Living Will: Yes ______No ______

Durable Power of Attorney for Health Care: Yes ______No ______Name: ______

Power of Attorney for Finances: Yes ______No ______Name: ______

Prescription Drug Card Name: ______Policy #: ______

Health Insurance Name: ______Policy #: ______

Nursing Home Insurance Name: ______Policy #: ______

Funeral Home Preference: ______Policy #:______

FINANCIAL INFORMATION

Room preference to resident: Semi-Private_____ Private_____Respite______

Medicare #: ______Social Security #: ______

How long will the individual’s financial status maintain:

One Year______Two Years ______Three Years ______More ______

CONTACT INFORMATION

In the order you wish them to be contacted please provide the following information for family members or friends.

Name______Spouse’s Name ______

Relationship______Home Phone ______Work______Cell______

Address ______City______State______Zip ______

Name______Spouse’s Name ______

Relationship______Home Phone ______Work______Cell______

Address ______City______State______Zip ______

Name______Spouse’s Name ______

Relationship______Home Phone ______Work______Cell______

Address ______City______State______Zip ______

Name______Spouse’s Name ______

Relationship______Home Phone ______Work______Cell______

Address ______City______State______Zip ______