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Shangri-La Care Home
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RESIDENT INTAKE FORM
First name
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Last name
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Phone
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Email
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Name of Resident
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Relation to Resident
*
Resident Age
*
Gender
*
Weight
*
Height
*
Do you already have an RN Assessment?
*
Yes
No
How did you hear about us?
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Relevant medical history (With dates/year, if known)
*
Reason for moving into an Adult Family Home
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Eating
*
Personal Hygiene
*
Mobility
*
Transferring
*
Bathing
*
Toileting
*
Memory Issues
*
Medication Assistance
*
Behavior
*
Skin Condition
*
Other information you want us to know
Current Living Condition
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Target Move In Date
*
Month
Would you like a summary of disclosures of our rates and services, including itemized services?
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Yes
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