Social History

I understand this application is not binding on myself or Meadows Mennonite Retirement Community, but is
simply indicates my interest in becoming a resident and provides general information necessary to determine
the type and amount of assistance I desire.

PLEASE COMPLETE ALL SECTIONS. THANK YOU.

Application Date

Email address of person completing this form

Referral Source: Hospital Physician Advertisement
                        Friend    Relative    Other

Personal Information

Full Name (First, Middle, Last)

Present Street Address (No PO Box)

City State Zip

County Telephone with Area Code

Maiden Name Preferred Name

Date of Birth Birthplace

Race/Nation Origin:

White/not of Hispanic Origin Black/not of Hispanic Origin

American Indian/Alaskan Native Hispanic

Asian/Pacific Islander

Educational Background

Previous Occupation

Employment Status: Employed Full Time Employed Part Time

Retired: No Yes - If yes, when

Marital Status: Single Married Widowed Divorced

Spouse's Name, if ever married

Spouse's Social Security Number

Date Married

If spouse is deceased, Date of Death

Veteran No Yes

Mother's Name Birthplace

Father's Name Birthplace

Name of Children:

1.

Complete Address

All Phone Numbers: Home

Work Cell

2.

Complete Address

All Phone Numbers: Home

Work Cell

3.

Complete Address

All Phone Numbers: Home

Work Cell

4.

Complete Address

All Phone Numbers: Home

Work Cell

Others:

Brothers, Sisters, and Other Close Relatives:

1. Phone Number

Complete Address

2. Phone Number

Complete Address

3. Phone Number

Complete Address

4. Phone Number

Complete Address

Others:

Person to Notify in an Emergency:

1. Phone Number

Complete Address

Relationship

2. Phone Number

Complete Address

Relationship

Person Available for Transportation to Appointments, Etc.:

1. Phone Number

Complete Address

Relationship

2. Phone Number

Complete Address

Relationship

Billing - Bills should be sent to:

Name

Telephone with Area Code

Street Address

City State Zip

Burial Arrangements:

In case of death, name of person who will make arrangements for the internment?

Telephone with Area Code

Funeral Director:

Address

City State Zip

Telephone with Area Code

Place of Internment:

City State Zip

Professional Data

List names, address and telephone number of each professional:

Present Physician

Address

City State Zip

Telephone with Area Code

Will you continue to be served by the physician above? Yes     No

Will you be served by the Meadows Home house physician? Yes     No

Medical Specialist

Address

City State Zip

Telephone with Area Code

Dentist

Address

City State Zip

Telephone with Area Code

Eye Doctor

Address

City State Zip

Telephone with Area Code

Pastor

Address

City State Zip

Telephone with Area Code

Church Telephone with Area Code

Advanced Directives

Do you have a living will? Yes     No

Does anyone have Power of Attorney for health? Yes     No

If yes, who?

Telephone with Area Code

Does anyone have Guardianship? Yes     No

If yes, who?

Telephone with Area Code

Does anyone have Power of Attorney for finances? Yes     No

If yes, who?

Telephone with Area Code

Do you drive a car? No      Yes

If yes, do you plan to use it at Meadows Home? Yes     No

Will your stay here be: Short Term     Long Term

Residential History

5 years prior to admission have you lived in the following: (please check one)

At this nursing home                At other nursing home

MR/DD setting                         MH/psychiatric setting

Other resident facility-board and care home, assisted living, group home

Own home by self                     Home with family/relative

Other

Physical Data

Does the applicant need assistance with:

Bathing                 Grooming

Dressing                Eating

Toileting                 Walking        Moving to a chair

Do you have trouble with your memory? Yes     No

Do you have or ever been diagnosed with a psychiatric problem? Yes     No

If yes, when and where treatment was received:

Date Period

Location

Do you have a diagnosis of dementia or Alzheimer's? Yes     No

If yes, when and where treatment was received:

Date Period

Location

Do you use: Tobacco   Yes     No       Alcohol   Yes     No   

*Please be advised that Meadows Mennonite Home is a non-smoking facility.  

Insurance Data

Social Security Number

Medicare Number

Medicaid Number

IPA Case Number

Medicare Coverage:   Part A Part B    OR None

Medicare Supplement Policy: No Yes

If yes, Company

Policy Number

Long Term Care Insurance: No Yes

If yes, Company

Policy Number

Other Insurance Company

Policy Number

Applicant's Statement

* I certify that answers given herein are true and complete to the best of my knowledge.  I authorize investigation
of all statements contained in this application for admission as may be necessary in arriving at an admission decision,
including but not limited to medical records from hospital, physician’s offices and other facilities and financial records.
Additionally, I will cooperate in the preparation, filling, signing and processing of necessary applications, reports or
documents for private, or government financial assistance program.  Meadows Mennonite Retirement Community may
release medical/billing information for purpose of claiming insurance benefits.  I understand that this application is not
intended to be a contract for care.

* Applicant Name Date

   Resident Representative Date

Interests - Simply put P for Past or C for Current

Crafts: Past or Current               Crocheting: Past or Current

Sewing: Past or Current             Needlework: Past or Current

Quilting: Past or Current             Painting: Past or Current

Music: Past or Current               Instrument: Past or Current

Radio: Past or Current                Reading: Past or Current

Large Print: Past or Current        Television: Past or Current

Poetry: Past or Current              Newspaper: Past or Current

Talking Books: Past or Current   Cards: Past or Current

Bingo: Past or Current               Sports: Past or Current

Cooking: Past or Current            Housework: Past or Current

Woodworking: Past or Current    Mechanics: Past or Current

Movies: Past or Current             Gardening: Past or Current  

Fishing: Past or Current             Picnics: Past or Current      

Walks: Past or Current              Bus Trips: Past or Current  

Shopping: Past or Current          Puzzles: Past or Current

Religious: Past or Current          Pets: Past or Current  

Vacations: Past or Current         Discussions: Past or Current

Visiting: Past or Current             Phone/Friends: Past or Current     

Volunteer: Past or Current          Entertainment: Past or Current  

Children: Past or Current          

Table Games - Specify: Past or Current

Active Games - Specify: Past or Current

Hobbies - Specify: Past or Current

Collections - Specify: Past or Current

Veteran:  No  Yes Dates of Service

                                       Branch of Service

Please list any other interests:

Please include a brief narrative of what makes your loved one smile:

Financial Information

Income:

Self -Pension/Retirement Plan per month $

Spouse -Pension/Retirement Plan per month $

Self -Rental Income per month $

Spouse -Rental Income per month $

Self -Dividends/Interest per month $

Spouse -Dividends/Interest per month $

Self -Other Sources of Income per month $

Spouse -Other Sources of Income per month $

Bank Account

Checking:

Self - Institution Account #

Balance $

Spouse - Institution Account #

Balance $

Savings:

Self - Institution Account #

Balance $

Spouse - Institution Account #

Balance $

CD/Money Market:

Self - Institution Account #

Balance $

Spouse - Institution Account #

Balance $

Other Capital Assets:

Self - Institution Account #

Balance $

Spouse - Institution Account #

Balance $

Real Estate

House: No Yes - Value $ Mortgage $

Land:  No Yes - Value $ Mortgage $

Vehicle: No Yes - Value $ Balance $

Other: No Yes - Value $

Mortgage/Balance $

Debt Obligations - Specify:

Amount $

Amount $

Mail Authorization

Resident will receive all mail delivered? No Yes

Please forward the following to guardian or power of attorney:

Business Letters           Bills           Checks

Personal Letters            Meadows Home Statements

Other - Specify

Consent to Criminal Background Check

According to the Vulnerable Adult Act, all nursing facilities are required to conduct criminal background checks for
prospective residents.

Have you ever been convicted of a felony?    No Yes

* I certify that answer given is true

* Applicant Name Date

   Resident Representative Date

If the answer is yes, Meadows Mennonite Home cannot admit you until the results of a State Police
criminal background check is returned to Meadows Mennonite Home. 

If the answer is no, we will proceed with the admission but a State Police criminal background check
will be conducted.  If the background check results indicate the applicant does have a criminal felony
history, Meadows Mennonite Home reserves the right to begin the discharge process immediately.