Long-Term Care Facility Admission Pre-Screening

Long-Term Care Facility Admission Pre-Screening — Form Fields

This healthcare template includes 9 fields. Families and case managers complete pre-screening for long-term care facility admission. Free to customize and use on ZenBuild.

• Resident Name (text, required)
• Date of Birth (text, required)
• Primary Diagnosis (text, required)
• Current Living Situation (dropdown selection, required) — options: Home with Family, Independent Living, Assisted Living, Hospital, Rehabilitation Facility
• Assistance Needed With (checkboxes, required) — options: Bathing, Dressing, Feeding, Mobility, Medication Management, Memory Care
• Primary Care Physician (text, required)
• Emergency Contact Name (text, required)
• Emergency Contact Phone (text, required)
• Does resident have advance directives? (multiple choice, required) — options: Yes, No, In Progress