Name

Phone

Email Address

Birthdate

Assisted Living or Memory Care? Assisted Living or Memory Care? Assisted Living Memory Care

Diagnosis of Dementia or Alzheimer's? Diagnosis of Dementia or Alzheimer's? Yes No

Gender: Gender: Male Female

Marital Status: Marital Status: Married Single Widow/er Divorced Separated

Current or former occupation:

Is there anyone helping you with your application? Is there anyone helping you with your application? Yes No

What is your current living situation?

Do you own a car? Do you own a car? Yes No

Do you intend to bring it? Do you intend to bring it? Yes No

Do you drive yourself regularly? Do you drive yourself regularly? Yes No

Who helps you at home?

How do they help you?

Do you have any services to assist you at home? If so, what service agencies and the types of assistance do they provide?

What is the reason you are considering supportive housing?

Are you currently in a Skilled Nursing Facility/Rehab? Are you currently in a Skilled Nursing Facility/Rehab? Yes No

Physician's Name:

Physician's Phone:

Please list any medical/health problems you have:

What medications are you currently taking? What medications are you currently taking? Yes No

Do you use oxygen? Do you use oxygen? Yes No

Do you require assistance/reminders to administer your medication(s)? Do you require assistance/reminders to administer your medication(s)? Yes No

Do you require assistance with a special diet or eating? Do you require assistance with a special diet or eating? Yes No

If so, describe:

Do you smoke? Do you smoke? Yes No

How do you enjoy spending your time? What hobbies do you enjoy?

How often do you use a computer or tablet?

Do you have a pet that you intend to bring? If so, what type?

Please check the task(s) you need assistance with: Please check the task(s) you need assistance with: Preparing Meals Eating/Feeding Self Walking Housekeeping Laundry Bathing Dressing Grooming Oral Care Safety due to poor judgement Finances Shopping

Do you use an assistive device? If so, what?

If you use a wheelchair, can you transfer in and out of it on your own? If you use a wheelchair, can you transfer in and out of it on your own? Yes No

What other assistance do you feel you need?

Do you have a long-term care policy that cover Assisted Living/Memory Care? Do you have a long-term care policy that cover Assisted Living/Memory Care? Yes No