APPLICATION FOR ADMISSION
Vonderlieth Living Center
1120 N. Topper Drive
Mt. Pulaski, IL 62548
217.792.3218
FAX 217.792.3210
Date: ________________________________
Applicant: ____________________________
Address: ______________________________
_______________________________
Contact Person/Power of Attorney:
Name: ________________________________
Address: ______________________________
Home Phone: __________________________
Cellular Phone: _________________________
Date: _____________________
Resident Name: ____________________________________________________
Address where living now: ___________________________________________
Phone: _______________________
Date of Birth __________________ Age: ____________
Social Security Number: __________________________
Medicare Number: ______________________________
Medicaid Number: Case: ___________________ Recipient Number: ________________
Supplemental Insurance:
Carrier: ______________________________________________
Policy/Claim Number: __________________________________
Legal:
Power of Attorney: ___________________________________
Guardian: ___________________________________________
Advanced Directives: DNR_______________ Full Code: _________________________
Marital Status M_____D_____W_____S_____ Spouse Name: ___________________
Maiden Name: ___________________________
Mothers maiden name: _____________________ Fathers Name: ___________________
Education Level: __________________________ Veteran Status: ___________________
Former Occupation: ________________________
Church Membership: _______________________________________________________
Previous Nursing Home Residency: _____________________________________
Hospitalizations:
MEDICAL DATA:
Primary Care Physician: ____________________________________________________
Address/Phone: _____________________________________________________
Specialty Physician's)
Dentist: ________________________________________________
Optometrist: ____________________________________________
Podiatrist: ______________________________________________
Hospital Preference: ______________________________________
Funeral Home: ___________________________________________
ALLERGIES TO FOOD OR DRUGS: ______________________________________
Circle all areas individual requires assistance with:
Bathing Dressing Grooming Walking Toileting
Eating
Continent of Bowel___________ Bladder_____________
Depends: ___________________ Attends: ____________
Wheelchair_________ Walker__________ Cane__________
Eyesight: _____________________________ Hearing: ____________________
Mental Status:
Alert knows others Can call others by name Knows time of day/date
Confused Anxious Agitated Depression
Behaviors exhibited:
Does individual wander outdoors if not closely supervised?
Medical/Health Problems:
Stroke Heart Condition Diabetes
Current Medications: If additional room needed, please attach list including all non-prescription drugs.
Date of last Flu vaccine: _________________________
Date of last pneumonia vaccine: ____________________
Other pertinent information:
FINANCIAL INFORMATION
Asset Current value/balance
Bank
Checking
Savings
CD
Money Market
Life insurance – Cash Value
Stocks/Bonds
Monthly Income:
Social Security
Pension
Life Estate
Annuities
Other
The following documents will need to be copied and attached:
Guarantor: ____________________________________________________________
Address: ______________________________________________________________
Phone: Home_____________________ Work______________ Cell______________
I hereby declare that my answers to the foregoing questions are full, complete, and true to the best of my knowledge and they shall form a part of my application for residency at Vonderlieth Living Center, Inc.
I hereby authorize any physician, hospital, or institution to furnish the Administrator of Vonderlieth Living Center, Inc. any information regarding the present or past condition of my health.
Date: ____________________________________
Applicant or Power of Attorney__________________________________________
Address: _____________________________________________________________