Gender *

Marital Status *

Does the primary caregiver live with the applicant? *

If no, living arrangements

Is the primary family caregiver employed?*

Has the applicant attended an Adult Day Program before? *

Preferred days for applicant to attend our center:

Will the applicant require assistance with medication while at the Center?*

Has the individual/family completed a: *If any of the above are marked, please provide a copy of the documents. Send copy to ucmjadcac@gmail.com *

Memory impairment?*

Is the client aware of Dementia diagnosis? *

Hearing Impairment: Right Ear *

Hearing Impairment: Left Ear *

Visual Impairment: Right Eye:*

Visual Impairment: Left Eye:*

Glasses *

Dentures: Upper*

Dentures: Lower *

Walking: Steady on his/her feet:*

Assistive Equipment:*

Diet *

Appetite:*

Eating:*

Swallowing: Does the applicant have problems swallowing his/her food? *

Swallowing: Does the applicant store food in his/her mouth?*

Swallowing: Does the applicant have problems with choking?*

Favorite morning beverage?*

Does he/she smoke or vape? Please note that we are a smoke/vape free facility) *

Toileting: Incontinent of bladder: *

Toileting: Incontinent of bowel: *

Toileting: Products used in daytime: *

If a wheelchair and physical assistance are used, is the applicant able to stand and support his/her weight long enough to safely transfer to the toilet (abt 2 min.)? *