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  1. sign
  2. Inquiry form for placement at Portage Manor (Form 2a)
  3. Financial Information
    Please check YES or NO to the following questions
  4. SSD*
  5. Medicare *
  6. SSI*
  7. Medicaid*
  8. VA*
  9. Vechicle*
  10. Home*
  11. Property*
  12. Burial Insurance*
  13. Health Insurance*
  14. Life Insurance*
  15. Checking Account*
  16. Savings Account*
  17. Medical Information
    Please check YES or NO to the following questions
  18. 1. Is there any history or evidence that the individual exhibits behavior that might present a danger to other residents, staff, and/or themselves?*
  19. 2. Does the individual have a documented diagnosis of intellectual disability, developmental delay, and/or other related conditions? *
  20. 3. Do they require assistance to ambulate? *
  21. 4. Do they dress themselves independently? *
  22. 5. Do they feed themselves independently and are able to chew and swallow without difficulty?*
  23. 6. Do they bathe themselves independently? *
  24. 7. Are they alert and oriented? *
  25. 8. Are they forgetful? *
  26. 9. Do they wander? *
  27. 10. Are they continent of bladder and bowel?*
  28. 11. Do they have special diet needs?*
  29. Internal Staff Only
  30. Leave This Blank:

  31. This field is not part of the form submission.