Health Histroy Form

Tuesday, 15 June 2010 20:19 Written by Administrator

Please fill out the Health History form below and submit it.  We will need this from along with the signature pages and personal history form for admissions.  If you have any questions at all please feel free to contact us at 641-257-3003.  We would be happy to answer any and all questions you may have.

Thank you,

Port Charles Administration

 

Health History
Application For Admission

Todays Date*

MM		/
DD		/
YYYY
Name*
Name*
Name*
Health Estimate*
In your own words estimate the condition of your health.
Vision is
Good 
Average 
Fair 
Poor 
Hearing is
Good 
Average 
Fair 
Poor 
Diagnosis: (CHF, Diabetes, etc.):
Specify any physical limitations:
Describe any allergy, include reactions to drugs
or foods:
Are you presently under special medical care?
Yes 
No 
If yes, for what?
Do you use:
Cane 
Crutches 
Walker 
Wheelchair 
If yes, describe and to what extent:
Do you have occasional memory loss/confusion?
Yes 
No 
If yes, describe to what extent.
Do you have occasional problems with bowel or
blader?
Yes 
No 
If yes, describe to what extent:
Do you require assistance with any task of
day-to-day living?
Bathing
Yes 
No 
Dressing:
Yes 
No 
Grooming:
Yes 
No 
Eating:
Yes 
No 
Cleaning:
Yes 
No 
Transportation:
Yes 
No 
If yes, describe and to what extent:
State any regular medicines and/or medical
treatments you recieve:
Do you have any current physical or emotional
conditions that keep you from doing the things
that you enjoy?
Yes 
No 
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Contact Information

Port Charles Assisted Living

801 Blunt Parkway * Charles City, Iowa 50616  * Phone: 641 257-3003  * Email: pcal@fiai.net * Web: pcalcc.com

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