Ill. Admin. Code tit. 77, § 330.APPENDIX C – Forms for Day Care in Long-Term Care Facilities

SAMPLE

APPLICATION FOR DAY CARE

FORM A

NAME

AGE

BIRTH DATE

ADDRESS

PHONE

SOCIAL SECURITY NUMBER

MEDICARE NUMBER

WITH WHOM DO YOU LIVE?

RELATIONSHIP?

PERSON TO CONTACT IN AN EMERGENCY

ADDRESS

PHONE

BUSINESS PHONE

PHYSICAL LIMITATIONS (please list)

SPECIAL PHYSICAL NEEDS (medications during day, special rest periods, etc. please list)

MEDICAL PROBLEMS (circle)

diabetic

hearing

subject to seizures

eyesight

heart disease

10.

assistance with meals

dizziness

11.

any paralysis

urinary control problem

12.

difficulty in walking

bowel control problem

13.

periodic confusion

special diet

14.

allergies (list)

15.

others

ARE YOU PRESENTLY UNDER A DOCTOR'S CARE?

NAME AND ADDRESS OF PHYSICIANS

SPECIAL INTEREST OR HOBBIES

DAYS ENTERED IN PROGRAMMING

A.M.

P.M

Monday

Tuesday

Wednesday

Thursday

Friday

DOYOU HAVE TRANSPORTATION?

(Source added at 9 Ill. Reg. 11049, effective July 1, 1985)

FORM B

SAMPLE

PHYSICIAN PERMISSION FORM

has applied for admittance to the day care program at

. Please supply the following information and also give written

permission for

to participate in the activity program.

Physical Limitations

Degree of activity

Can day care resident be involved in activities outside of the facility

(in the community)?

Has

been evaluated within the last 30 days

and found to be free of communicable and infectious disease?

Medications and/or treatments and diet needed by day care resident during

the period of time spent in the facility.

Can day care resident take own medication?

Allergies

Date:

Signature of Physician:

(Source: Added at 9 Ill. Reg. 10974, effective July 1, 1985)