Initial Applicant Information – Lincoln Hill Manor

Lincoln Hill Manor

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Lincoln Hill Manor

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Initial Applicant Information

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Initial Applicant Information

Initial Applicant Information (Download)

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LINCOLN HILL MANOR

53 Lincoln Street Spencer MA 01562
(508) 885-3338

Initial Applicant Information

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Name

Gender

Medicare #

Health Insurance Co.

DOB

SSN

MA Health #

ID #

Home Address

Current Address

Contacts

1

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Name - 1

Telephone - 1

Relationship - 1

Email - 1

Address - 1

2

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Name - 2

Telephone - 2

Relationship - 2

Email - 2

Address - 2

3

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Guardian

Guardian - Telephone

4

Power of Attorney (POA)?

Yes
No

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POA Name

POA Telephone

5

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Physician Name

Physician Telephone

Current Mental State

Current Mental State

Alert
Agitated
Withdrawn
Oriented
Cooperative
Suicidal
Confused
Uncooperative at times
Pleasant
Forgetful
Combative
Aggressive
Rational
Violent

Memory loss

Short Term
Long Term

Does applicant ambulate independently?

Yes
No

Does applicant use a personal walker or a cane?

Yes
No

Can applicant do four stairs?

Yes
No

Can applicant do a flight of stairs?

Yes
No

Does applicant currently have physical/occ. therapy?

Yes
No

Has applicant been having hallucinations or arguments?.

Yes
No

Has applicant been striking out or exhibiting violent behavior?

Yes
No

Has applicant been having delusions, depression, agitation?

Yes
No

Is applicant cognitively impaired?

Yes
No

Does applicant have any prosthetic devices?

Yes
No

Specify

Does applicant have any rashes or skin issues?

Yes
No

Specify

Does applicant have any Edema?

Yes
No

Where

Please list Falls in the past year, circumstances, and any injuries:

Current Diagnoses/Medications

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Social Security - Monthly Income - $

VA Pension - Monthly Income - $

Pension - Monthly Income - $

Long Term Care Insurance - Monthly Income - $

Other - Monthly Income - $

Total Income - Monthly Income - $

Social Security - Expenses

VA Pension - Expenses

Pension - Expenses

Long Term Care Insurance - Expenses

Other - Expenses

Total Income - Expenses

Veteran Information

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Is applicant a veteran?

Yes
No

Is applicant’s spouse a veteran?

Yes
No

Dates of Service

VA Contact Name

VA Contact Tel

Assets

1

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Name of bank - 1

Account type - 1

Account - 1 #

Current balance $ - 1

2

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Name of bank - 2

Account type - 2

Account - 2 #

Current balance $ - 2

3

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401K/Pension Balance $

Details

4

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Trust Fund Balance $

Details

5

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Investment Account Face Value $

Details

6

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Stocks and Bonds Face Value $

Details

7

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Does applicant own a car?

Yes
No

Car Face Value $

8

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Does applicant own a home?

Yes
No

Home Mortgage $

Home Face Value $

Lien on Home

9

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Does applicant have life insurance?

Yes
No

Insurance Cash Value $

10

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Other assets

Face Value $

Transferred Assets

Has applicant transferred assets to another person in the last 5 years?

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List Persons - 1

List Persons - 2

List Persons - 3

Asset - 1

Asset - 2

Asset - 3

Asset/Value - 1

Asset/Value - 2

Asset/Value - 3