Statutes, codes, and regulations
Illinois Administrative Code
Title 77 - PUBLIC HEALTHPart 300 - SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODESubpart U - ALZHEIMER'S SPECIAL CARE UNIT OR CENTER PROVIDING CARE TO PERSONS WITH ALZHEIMER'S DISEASE OR OTHER DEMENTIA
Appendix D - Forms for Day Care in Long-Term Care Facilities
Form A

Ill. Admin. Code tit. 77 , U, Appendix D, Form A

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Current through Register Vol. 48, No. 25, June 21, 2024
Form A

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)

1. _________________________

2. _________________________

3. _________________________

4. _________________________

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

1. _____________________

4. ____________________

2. _____________________

5. ____________________

3. _____________________

6. _________________________

MEDICAL PROBLEMS (circle)

1. diabetic

8. hearing

2. subject to seizures

9. eyesight

3. heart disease

10. assistance with meals

4. dizziness

11. any paralysis

5. urinary control problem

12. difficulty in walking

6. bowel control problem

13. periodic confusion

7. 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

_____________

___________________

DO YOU HAVE TRANSPORTATION? ______________________________

Ill. Admin. Code tit. 77 , U, Appendix D, Form A

Added at 9 Ill. Reg. 11049, effective July 1, 1985