Nursing Home Patient Intake Form
Nursing Home Patient Intake Form
Please fill out this form to provide essential information for the care and support of your loved one.
Resident Information
Full Name
Date of Birth
Address
Phone number
Emergency Contact Information
Primary Contact Name
Relationship to Resident
Phone number
Alternate Contact Name
Relationship to Resident
Phone number
Medical History
Primary Care Physician Name
Primary Care Physician Phone Number
Medical Conditions (Chronic illnesses, etc.)
Medications (Current and past)
Allergies (Food, medication, etc.)
Past Surgeries or Hospitalizations
Immunization History
Insurance Information
Insurance Company Name
Policy Number
Group Number
Phone number
Personal Preferences and Special Needs
Dietary Preferences or Restrictions
Special Accommodations Needed (e.g., mobility aids, hearing devices)
Preferred Activities or Hobbies
Religious or Cultural Considerations
Legal Documents
Power of Attorney (if applicable)
Advance Directives (Living Will, DNR, etc.)
Guardianship Information (if applicable)
Resident
Name:
Date:
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