Maple Lawn Medical Care Facility 50 Sanderson Lane Coldwater, MI 49036 | Patient Waiting List Admission Questionnaire |
Patient Information |
Date | 02/19/2025 |  |  |
Name |
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Address
Line 2
City, ST Zip |
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Phone Number |
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Are you a Branch County Resident? |
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Have you ever been a resident at Maple Lawn Medical Care Facility? |
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If Yes, When? |
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Date of Birth |
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Gender |
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Social Security Number |
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Medicare Number |
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Medicaid Number |
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Private Insurance |
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Are you a member of a Health Maintenance Organization (HMO)? |
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HMO Name |
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Insured's Name |
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Policy Number |
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HMO Address
Line 2
City, ST Zip |
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Insurance Company Address
Line 2
City, ST Zip |
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Insurance Company or HMO Phone Number |
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If you do not have private insurance, Medicaid or Medicare, please give the name of the person responsible for private payment: |
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Medical Information
Medical information needs to be filled out so it can help us to determine if patient is eligible for admission. |
Primary Diagnosis |
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Other Medical Conditions |
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Physician Referring This Patient |
Name |
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Address
Line 2
City, ST Zip |
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History of mental Illness? |
- If Yes, describe:
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History of behavior problems? (Wanders, Combative, etc) |
- If Yes, describe:
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Speech |
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Hearing |
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Sight |
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Mental Status |
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Diet |
- If Other, Please Specify:
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Activities Of Daily Living |
Dressing |
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Bathing |
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Ambulation |
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Feeding |
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Bladder Control |
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Bowel Control |
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Is patient independent in toileting |
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Does patient have any known drug allergies or sensitivities |
- If Yes, Please Specify
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Does patient require oxygen |  |
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Does patient have any skin problems or wounds? |
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If Yes, please describe and give location |
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Does patient require any other special treatments? |
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If Yes, please describe (Tracheostomy, Colostomy, Feeding Tube, etc)
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Current Medications |
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Have there been any hospital stays within the last 6 months? |
- If Yes, please specify the dates:
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Does the patient have any Advance Directives, Living Will, Guardian, or Durable Power of Attorney?
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If Yes, please specify |
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Contact Information |
Primary Contact |
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Relationship |
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Address
Line 2
City, ST Zip |
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Home Tel. Number |
| Work Tel. Number |
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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 |
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Telephone |
| Telephone |
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