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Pre-Screening for Admission to Portage Manor (Form 2b)

  1. sign
  2. Pre-Screening for Admission to Portage Manor (Form 2b)
  3. Religious Information
  4. Church Notified of Admission:
  5. Name(s) of interested family or friends and relationship(s)
  6. Is resident still active in these?
  7. Is resident able to write own Letters/Documents?
  8. Is resident able to Read/Understand own mail?
  9. Manage Phone?
  10. Medical Information
    This section must be completed by a licensed nurse prior to admit
  11. Is resident:
  12. Vision:
  13. Utilized Hearing Aides?
  14. Diabetic:
  15. Insulin Dependent?
  16. Can they self administer?
  17. Requires Oxygen?
  18. Updraft Tx?
  19. Leave This Blank:

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