Siesta Haven Corporation

ADULT FAMILY CARE

PO Box 3715, Brewer, Maine 04412 Wendy Lainez-Blanchard

(207)944-6328Fax: 989-5322 Owner/administrator

We specialize in Seniors

ENROLLMENT APPLICATION

for Siesta Haven, Siesta Haven II and The Burr Home

  1. RESIDENT INFORMATION:

Name:______Date: ______

Address: ______

Phone: ______

Birthday: ______Social Security: ______

Medicare#: ______MaineCare#: ______

Monthly Income:______

Living situation: (check all that apply) Type of residence: (check all that apply)

  • Living alone
  • With spouse
  • With adult child
  • With other relative(s)
  • With non-relative
  • house/apartment
  • retirement housing
  • foster care/assisted living
  • other (specify)

  1. RESIDENT’S HEALTH INFORMATION:

Current medical history/diagnosis:______

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List current medications:______

Any known allergies?

Primary health care provider (Physician, P.A., F.N.P.)

Name:______

Address:______

Phone:______fax:______

Additional health care providers:

Name:______

Address:______

Phone:______

Does the resident have a court appointed legal guardian? YesNo

Does the resident have a power of attorney?YesNo

If yes, please give name and address:______

HOSPITAL PREFERENCE:PHONE:

  1. EMERGENCY INFORMATION:

Name:______Relationship:______

Address: ______

Phone: (home)______(cell)______(work)______

If primary contact is unavailable, please identify additional emergency contacts:

Name:______Relationship:______

Phone:______

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  1. CAREGIVING INFORMATION,

Describe how much help you give to your family member in the following:

  • Bathing = none - some – total
  • Toileting = none – some – total
  • Dressing = none – some – total
  • Moving in/out of chairs = none – some – total
  • Eating = none – some – total
  • Using phone = none – some – total
  • Taking medication = none – some – total

In the past week, how many days did you personally have to deal with the following behaviors:

  • Keep you up at night = 1 to 2 days – 3 to 4 days – 5 days or more
  • Repeat questions/statements = 1 to 2 days – 3 to 4 days – 5 days or more
  • Bowel or bladder “accident” = 1 to 2 days – 3 to 4 days – 5 days or more
  • Forger where belongings were placed = 1 to 2 days – 3 to 4 days – 5 days or more
  • Cry easily = 1 to 2 days – 3 to 4 days – 5 days or more
  • Act depressed = 1 to 2 days – 3 to 4 days – 5 days or more
  • Cling to you or follow you around = 1 to 2 days – 3 to 4 days – 5 days or more
  • Become irritable/angry = 1 to 2 days – 3 to 4 days – 5 days or more
  • Threaten people = 1 to 2 days – 3 to 4 days – 5 days or more
  • Become restless or agitated = 1 to 2 days – 3 to 4 days – 5 days or more

Any other behavior information: ______

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HEALTH Conditions: (check all that apply):

  • Seizures
  • Heart disease
  • Swallowing/choking
  • Dizziness/fainting
  • High/low blood pressure
  • Heat/cold sensitivity
  • History of falls
  • Diabetes
  • Other (please explain)______

Dietary restrictions:

  • Low fat
  • Low sodium
  • Diabetic
  • Other (please explain)______

Eating assistance:

  • Independent
  • Verbal cueing
  • Some assistance
  • Complete assistance

Special equipment used:

  • Hearing aids
  • Glasses
  • Dentures
  • Walker
  • Cane
  • Wheelchair
  • Other (please explain)______

Behavioral/mental attitudes:

  • Sociable
  • Cooperative
  • Alert
  • Cheerful
  • Noisy
  • Depressed
  • Wanderer
  • Agitated
  • Confused
  • Talkative
  • Withdrawn
  • Other ______

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Assistance Needed:

  • Standing
  • Walking
  • Toileting
  • To/from seated position
  • With dressing, shoes
  • Other ______
  1. SOCIAL INFORMATION:

The following information will enable the staff to help the resident increase self-esteem, physical abilities, and social contact.

Languages spoken (past and present)______

If unable to speak, describe how participant communicates______

Marital status: ______

Number of years married (if applicable):______

Number of children (if applicable):______

Former home: ______

Former Occupation: ______

Religious affiliation: ______

Favorite topics of conversation: ______

Sensitive topics: ______

Interest/Hobbies past and present (check all that apply):

  • Reading
  • Games
  • Crafts
  • Outings
  • Music
  • Lectures

  • Sewing
  • Cooking
  • Singing
  • Sports
  • Walking
  • Woodworking
  • Collecting
  • Gardening
  • Movies
  • T.V.

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  • Musical instrument
  • Exercise
  • Bingo
  • Cards
  • Other

AN AMBULANCE WILL BE CALLED IN CASE OF MEDICAL EMERGENCY

6. BILLING INFORMATION:

Person responsible for payment______

  • Private Pay
  • MaineCare
  • Long Term Care Insurance

Please identify:______

AUTHORIZATION:

All information is correct as given on this date: ______

Signature of resident:______

Signature of responsible party:______

Signature of Siesta Haven’s administrator:______

I give permission for Siesta Haven to verify any information provided.

Signature of resident or person responsible:______

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