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2. 
3. Inquiry form for placement at Portage Manor (Form 2a)
5. Name of Inquirer:*
7. Relationship to Prospective Resident:
8. Phone #:
12. Prospective Resident:*
13. D.O.B.*
14. Age: *
16. Gender: *
17. Where have they been Living?*
19. How did they hear about Portage Manor?*
    -- Select One --FriendNewsDoctorOther
20. What is their Diagnosis?*
22. Primary Care Doctor: *
23. Phone #: *
25. Specialist/Psychiatrist: *
26. Phone #: *
30. Financial Information
    Please check YES or NO to the following questions
32. SSD*

    1. YES
    2. No
33. If Yes, the Amount $:
34. Medicare *

    1. YES
    2. NO
35. If Yes, the Policy Number #:
37. SSI*

    1. YES
    2. NO
38. If Yes, the Amount $:
39. Medicaid*

    1. YES
    2. NO
40. If Yes, the Policy Number #:
42. VA*

    1. YES
    2. NO
43. If Yes, the Amount $:
45. Vechicle*

    1. YES
    2. NO
46. If Yes, the Year, Make, Model, & Estimated Value:
48. Home*

    1. YES
    2. NO
49. If Yes, the Address & Estimated Value:
51. Property*

    1. YES
    2. NO
52. If Yes, the Type, Location, & Estimated Value:
54. Burial Insurance*

    1. YES
    2. NO
55. If Yes, Company Name:
57. Health Insurance*

    1. YES
    2. NO
58. If Yes, Company Name:
60. Life Insurance*

    1. YES
    2. NO
61. If Yes, Company Name:
63. Checking Account*

    1. YES
    2. NO
64. Savings Account*

    1. YES
    2. NO
65. If Yes, Bank Name & Account Number(s):
69. Medical Information
    Please check YES or NO to the following questions
71. 1. Is there any history or evidence that the individual exhibits behavior that might present a danger to other residents, staff, and/or themselves?*

    1. YES
    2. NO
73. 2. Does the individual have a documented diagnosis of intellectual disability, developmental delay, and/or other related conditions? *

    1. YES
    2. NO
75. 3. Do they require assistance to ambulate? *

    1. YES
    2. NO
77. 4. Do they dress themselves independently? *

    1. YES
    2. NO
79. 5. Do they feed themselves independently and are able to chew and swallow without difficulty?*

    1. YES
    2. NO
81. 6. Do they bathe themselves independently? *

    1. YES
    2. NO
83. 7. Are they alert and oriented? *

    1. YES
    2. NO
85. 8. Are they forgetful? *

    1. YES
    2. NO
87. 9. Do they wander? *

    1. YES
    2. NO
89. 10. Are they continent of bladder and bowel?*

    1. YES
    2. NO
91. 11. Do they have special diet needs?*

    1. YES
    2. NO
92. If Yes, what are they?
96. What are your expectations for living at Portage Manor?*
100. Internal Staff Only
102. Inquiry Date
     Inquiry Date
103. Reviewed by:
104. Entered in EMR:
Leave This Blank:


106. 1. Receive an email copy of this form.
107. Email address

     This field is not part of the form submission.

108. Submit Submit and Print

* indicates a required field