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General Information (Applicant Information)
Name: ____________________ Address: ____________________ City: ____________________ State: ____________________ Zipcode: ____________________ Marital Status: ____________________ Term Choice: Short ___ Long ___ Still Drive? Yes ___ No ___		Date of Birth: __________________ Desired Date of Residency:   __________________ Home Phone: __________________ Social Sec #: __________________ Sex (M or F): __________________ Doctor: __________________ Bring Car? __________________

Contact Party (Closest Relatives)   Name: ____________________ Address: ____________________ City: ____________________ State: ____________________ Zipcode: ____________________ Phone: ____________________ Relationship: ____________________ Name: ____________________ Address: ____________________ City: ____________________ State: ____________________ Zipcode: ____________________ Phone: ____________________ Relationship: ____________________

Resident Medical Information
Recent:	________________________________________________________ ________________________________________________________ ________________________________________________________
Past:	________________________________________________________ ________________________________________________________ ________________________________________________________
Current Medications: ______________________________________________
Smoker: Yes ___ No ___   Drink Alcohol: Yes ___ No ___
Does Resident Use: Cane ___ Walker ___ Wheelchair ___ None ___
Continent of: Urine ___ Stool ___ Frequency of Problem: ____ / week
Medical Insurance Provider: ______________________________________
Financial Information
Monthly Income From: Social Security $________ Pension $________ Other $________ Total $________ Drug Payment Plan (PACE, etc.): __________________________________

Grand View Manor, 129 Houck Road, Fleetwood, PA 19522 Phone: (610) 944-1800   Toll Free: (866) 944-1800   Fax: (610) 944-5200

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