Better Living Lifestyle | Senior Residential Care & Placement Services | Edmonds, WA

Client Name

Primary Contact

Relationship to Client

Contact's Phone Number

Contact's Email

Referral Source

Client's Age

Sex

Skin:
Intact
Open
Bruises

Current Location

Price Range

Payment Method:
Private Pay
Medicaid
Long Term Care
Conversion to Medicaid in Future

Desired Location

Diagnosis

Primary Care Physician

Medical Group

Medical History

Alergies

Medications

Treatment

Mental Status:
Oriented
STM-Confusion
Agitation
Depression
Anxiety
Exit Seeking
Up at Night

Ambulation:
Independent
Assistance
Wheel Chair
Cane
Walker
Bed Bound
Hoyer

Bathing:
Independent
Assist
Total Assist
Cue or Setup

Dressing:
Independent
Assist
Total Assist

Toileting:
Continent
Incontinent
Inappropriate

Feeding:
Independent
Assist
Cue or Setup

Diet

Appetite

Personality

Pets

Likes and Dislikes

Religious or Cultural Preferences

Name:

Phone:

I'm looking for care options in: City

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