Maple Lawn Medical Care Facility
50 Sanderson Lane
Coldwater, MI 49036

Patient Waiting List Admission Questionnaire

Patient Information

Date12/04/2022
Name
Address
Line 2
City, ST Zip


,
Phone Number
 
Are you a Branch County Resident?
Have you ever been a resident at Maple Lawn Medical Care Facility?
If Yes, When?
 
Date of Birth
Gender
Social Security Number
Medicare Number
Medicaid Number
Private Insurance
 
Are you a member of a Health Maintenance Organization (HMO)?
HMO Name
Insured's Name
Policy Number
HMO Address
Line 2
City, ST Zip


,
Insurance Company Address
Line 2
City, ST Zip


,
Insurance Company or HMO Phone Number
If you do not have private insurance, Medicaid or Medicare, please give the name of the person responsible for private payment:
 

Medical Information

Medical information needs to be filled out so it can help us to determine if patient is eligible for admission.

Primary Diagnosis
Other Medical Conditions
 

Physician Referring This Patient

Name Phone #
Address
Line 2
City, ST Zip


,
 
History of mental Illness? - If Yes, describe:
History of behavior problems? (Wanders, Combative, etc) - If Yes, describe:
Speech
Hearing
Sight
Mental Status
Diet - If Other, Please Specify:
 

Activities Of Daily Living

Dressing
Bathing
Ambulation
Feeding
Bladder Control
Bowel Control
 
Is patient independent in toileting
 
Does patient have any known drug allergies or sensitivities - If Yes, Please Specify
Does patient require oxygen
Does patient have any skin problems or wounds?
If Yes, please describe and give location
Does patient require any other special treatments?
If Yes, please describe (Tracheostomy, Colostomy, Feeding Tube, etc)
 
Current Medications
 
Have there been any hospital stays within the last 6 months? - If Yes, please specify the dates:
 
Does the patient have any Advance Directives, Living Will, Guardian, or Durable Power of Attorney?
If Yes, please specify
 

Contact Information

Primary Contact
Relationship
Address
Line 2
City, ST Zip


,
Home Tel. Number Work Tel. Number
 
Alternate Contacts (Please list an alternate in the event that the primary contact cannot be reached. We need to be able to reach this party between the hours of 8:00 AM & 4:00 PM
Alternate #1 Name Alternate #2 Name
Telephone Telephone