TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: LONG-TERM CARE FACILITIES
PART 390 LONG-TERM CARE FOR UNDER AGE 22 FACILITIES CODE
SECTION 390.APPENDIX B FORMS FOR DAY CARE IN LONG-TERM CARE FACILITIES


 

Section 390.APPENDIX B  Forms for Day Care in Long-Term Care Facilities

 

APPENDIX B

Form A

 

Sample

Forms for Day Care in Long-Term Care Facilities

 

APPLICATION FOR DAY CARE

 

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?

 

 

 


 

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:  Former Appendix B renumbered to Section 390.3510, new Appendix B adopted at 9 Ill. Reg. 10785, effective July 1, 1985)