| Your name: |
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| Phone Number: |
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| Email address: |
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| Potential Resident Name: |
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| Time Frame to Move In: |
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| Current Location: |
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| Medical Diagnosis: |
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| Current Medications (including over the counter & PRN meds): |
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| Diet: |
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| Cognitive Status/Memory Impairment: |
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| Vision: |
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| Mobility: |
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| General Personality/Interests: |
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| Important Features to Client: |
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| Notes or Comments: |
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