Name (required)

    Maiden

    Telephone Number (required)

    Home Address (required)

    Address Prior to Admission

    Date of Birth (required)

    Marital Status (required)
    MarriedSingleWidowedDivorced

    Sex (required)
    MaleFemale


    Last 4 of Social Security Number

    Medicare Number

    Hospital/Health Insurance

    Claim Number

    Medicare Prescription Drug Plan (if applicable)

    Has applicant applied for Medicaid/County Assistance?
    YesNo

    Medicaid Billing Number: (if applicable)


    Physician

    Hospital Preference

    Optometrist

    Dentist


    Funeral Home Preference

    Funeral Home Telephone Number

    Church Affiliation

    City

    Pastor’s Name

    Church Telephone Number


    Does the applicant have any of the following?:

    Durable Power of Attorney for Finances
    YesNo

    Health Care
    YesNo

    Court-Appointed Guardian
    YesNo

    Living Will
    YesNo

    Please provide copies at time of admission.


    List the name of children, other family, or significant others. List primary contact/DPOA or guardian FIRST. Statement should be sent (if different from primary contact below):

    Family Contact #1 (Primary Contact/DPOA or Guardian)

    Name

    Relationship

    Address

    Home Telephone Number

    Work Telephone Number


    Family Contact #2

    Name

    Relationship

    Address

    Home Telephone Number

    Work Telephone Number


    Family Contact #3

    Name

    Relationship

    Address

    Home Telephone Number

    Work Telephone Number


    Family Contact #4

    Name

    Relationship

    Address

    Home Telephone Number

    Work Telephone Number


    Family Contact #5

    Name

    Relationship

    Address

    Home Telephone Number

    Work Telephone Number


    Family Contact #6

    Name

    Relationship

    Address

    Home Telephone Number

    Work Telephone Number


    Medical History

    Please note whether each condition is something applicant is currently dealing with, historical or not applicable. Give approximate dates condition occurred if possible and specifics as applicable (i.e. allergies-penicillin). Additional space is provided below if you need more space for explanation or to note problems/conditions not listed here.

    Heart Attack

    Details


    Stroke

    Details


    Cancer

    Details


    Diabetes

    Details


    Sores

    Details


    Congestive Heart Failure

    Details


    Arthristis

    Details


    Tuberculosis

    Details


    Special Diet

    Details


    Bowel/Bladder Problems

    Details


    Recent Falls/Injuries

    Details


    Depression/Anxiety

    Details


    Mental Illness

    Details


    Mental Retardation

    Details


    Mental Condition

    Details


    Problems with Vision

    Details


    Problems with Hearing

    Details


    Problems with Speech

    Details


    Appliances Used (Check all that apply):
    NoneWheelchairWalkerCaneBraceProsthesisPacemaker

    Details


    Alcohol and or Other Drug Abuse

    Details


    Cigarette Smoker

    Details


    Physical Abusive Behaviors/Aggression

    Details


    Sexual Aggression

    Details


    Suicidal Ideations or Attempt

    Details


    Non-Compliance with Medication Use

    Details


    List additional information and or needs here:


    Social History

    Mother’s Name (First & Maiden)

    Father's Name

    List names of living and deceased brothers & sisters

    Highest grade of education completed (list and degrees, colleges attended)

    Primary Occupation

    Other Occupations

    Date of Retirement (From Where)

    Are you a veteran? (Give dates/branch of service)

    Does the applicant receive VA benefits?
    YesNo

    Marital Information (If Applicable)

    Date of Marriage (Spouse 1)

    Spouse’s Name(s)/Maiden (Spouse 1)

    Date of Death/Divorce (Spouse 1)


    Date of Marriage (Spouse 2)

    Spouse’s Name(s)/Maiden (Spouse 2)

    Date of Death/Divorce (Spouse 2)


    Date of Marriage (Spouse 3)

    Spouse’s Name(s)/Maiden (Spouse 3)

    Date of Death/Divorce (Spouse 3)


    List names of children and note those that are living and deceased

    Other Significant Relationships

    Past or Present Hobbies/Pastimes

    Past or Present Involvement in Organizations, Groups, Clubs, etc.

    Special Accomplishments, Awards Earned, etc.


    Disclaimer and Acceptance

    I agree to be responsible for payment of expenses from the applicant/resident’s funds. If payments are two months late, I agree that the outstanding balance shall bear monthly interest at the two points above the prime rate then being published in the Wall Street Journal effective January first of the current year until the full amount is paid. The party or parties executing this agreement shall be personally liable for any remaining balance due on the account upon the death of the resident, and such party or parties agree to indemnify and hold harmless Fairlawn Haven Nursing Home against any expense incurred in the collection of such balance. Estimated length of time resident will be able to private pay nursing home expenses.

    Fairlawn Haven Care Center is not-for-profit and is Medicaid/Medicare approved. If you have limited resources, you may qualify for benefits through the County Job and Family Services@ 419-337-0010.

    OUR LIFE CARE AGREEMENT. NO PERSON SHALL BE DISCHARGED FOR LACK OF FUNDS.

    If admitted, I promise to do all within my power to promote a pleasant atmosphere in the Home, and comply with all rules and regulations of the Home.

    Please check the box below to indicate your acceptance of the terms and conditions. (required)

    Please check the box below to confirm that you are authorized to complete this application and provide this detailed medical and personal information. (required)

    Name of Applicant or Legal Representation

    Date (required)


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