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)


Prove to us you're a human. Please type the text from the image in the field below:
captcha