Maple Lawn Medical Care Facility 50 Sanderson Lane Coldwater, MI 49036		Patient Waiting List Admission Questionnaire
Patient Information
Date	11/19/2024
Name
Address Line 2 City, ST Zip	,
Phone Number

Are you a Branch County Resident?			Yes No
Have you ever been a resident at Maple Lawn Medical Care Facility?			Yes No
If Yes, When?

Date of Birth
Gender	Male Female
Social Security Number
Medicare Number
Medicaid Number
Private Insurance

Are you a member of a Health Maintenance Organization (HMO)?			Yes No
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?		Yes No - If Yes, describe:
History of behavior problems? (Wanders, Combative, etc)		Yes No - If Yes, describe:

Speech	Normal Impaired Absent
Hearing	Normal Impaired Absent
Sight	Normal Impaired Absent

Mental Status	Alert Confused at times Always Confused Comatose or Semicomatose
Diet	Regular Low Salt Diabetic Other - If Other, Please Specify:

Activities Of Daily Living
Dressing	Independant Needs some assistance Completely dependant
Bathing	Independant Needs some assistance Completely dependant
Ambulation	Independant Needs some assistance Completely dependant
Feeding	Independant Needs some assistance Completely dependant
Bladder Control	Complete Control Some Control No Control Has Catheter
Bowel Control	Complete Control Some Control No Control

Is patient independent in toileting		Yes No

Does patient have any known drug allergies or sensitivities		Yes No - If Yes, Please Specify
Does patient require oxygen		Yes No
Does patient have any skin problems or wounds?		Yes No
If Yes, please describe and give location
Does patient require any other special treatments?		Yes No
If Yes, please describe (Tracheostomy, Colostomy, Feeding Tube, etc)

Current Medications

Have there been any hospital stays within the last 6 months?		Yes No - If Yes, please specify the dates:

Does the patient have any Advance Directives, Living Will, Guardian, or Durable Power of Attorney? Yes No
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