Patient Application Contact Information *Name *What is your relationship with the patient? *Email address *Phone Patient information *Date of birth *Can the patient eat by him/herself? *Does the patient have a special diet? *Can the patient speak? *Which language does he/she speak? *What is the patient's weight? *Does the patient have a chronic condition? *Can the patient walk by him/herself? *Is the patient on bed most of the time? *Does the patient use adult diapers? *Do you desire a private or shared room? *What is your monthly budget limit? *The patient has a chronic or degenerative disease? *On a scale from 1-10, what do you consider the patient’s memory level? *Does the patient need hospice care? Any other comments, please state