Form Center

2. 
3. Pre-Screening for Admission to Portage Manor (Form 2b)
5. Name: *
6. Attending Physican Name:*
8. D.O.B. *
9. Age:*
10. Birthplace:
11. Admission Date:*
    Admission Date:
13. SS#: *
14. SSI Account #: *
15. SSD Amount:*
17. Medicaid #:
18. Medicare #:
19. Marital Status:
    -- Select One --SingleMarriedDivorcedWidowed
21. Former Occupation:
22. Primary Language:
26. Religious Information
28. Religious Faith:
29. Name of Minister/Priest:
30. Church Membership:
31. Church Phone #:
33. Church Notified of Admission:

    1. YES
    2. NO
37. Education Level:
    -- Select One --GED DegreeHigh School DegreeBA DegreeMaster Degree
38. Special Skills/Training
39. Cultural/Ethinic Background:
40. Military Branch of Service:
44. Does the resident have any outstanding legal issues or history of such?
46. Living Arrangements & Address prior to Admission:
48. Reason for Admission:
52. Name(s) of interested family or friends and relationship(s)
54. Name 1:
55. Relationship:
56. Email:
58. Address
60. City
61. State
62. Zip Code
64. Name 2:
65. Relationship:
66. Email:
68. Address
70. City
71. State
72. Zip Code
74. Name 3:
75. Relationship:
76. Email:
78. Address
80. City
81. State
82. Zip Code
86. Who will handle resident’s personal fund?
87. Payee?
89. What Organization/Clubs does resident belong to?
90. Is resident still active in these?

    1. YES
    2. NO
92. Is resident able to write own Letters/Documents?

    1. YES
    2. NO
93. Is resident able to Read/Understand own mail?

    1. YES
    2. NO
94. Manage Phone?

    1. YES
    2. NO
95. Cell#:
97. Resident’s attitude toward placement?
99. Family’s attitude toward placement?
101. SSD/Designee Signature:
102. Date:
     Date:
106. Medical Information
     This section must be completed by a licensed nurse prior to admit
108. Is resident:

     1. Alert
     2. Confused
     3. Oriented
     4. Cheerful
     5. Agitated
109. Speech:
111. Vision:

     1. Glasses
     2. Poor
     3. Nearly Blind
     4. Blind
112. Ambulatory Status:
114. Hearing:
115. Utilized Hearing Aides?

     1. YES
     2. NO
116. If Yes, what ear? Right or Left
118. Diet:
119. ADL's:
120. Continent of bowel/bladder:
122. Dx:
124. Diabetic:

     1. YES
     2. NO
125. Insulin Dependent?

     1. YES
     2. NO
126. Can they self administer?

     1. YES
     2. NO
128. Lung sounds:
129. Biox?
130. Requires Oxygen?

     1. YES
     2. NO
131. Updraft Tx?

     1. YES
     2. NO
133. Does this prospect meet residential level of care for Portage Manor?
134. Medical Director Approved?
136. Assessing Nurse Signature:
137. Date:
     Date:
Leave This Blank:


139. 1. Receive an email copy of this form.
140. Email address

     This field is not part of the form submission.

141. Submit Submit and Print

* indicates a required field