Intake Forms- DISCHARGE PLANNING July 18, 2011 By Maunalani Staff Maunalani Nursing & Rehabilitation Center DISCHARGE PLANNINGName First Last Admission Date InsuranceCompleted form withWhat type of dwelling do you currently occupy?Stairs No Yes How many steps?Please enter a number from 0 to 99.Railing on which side going up?Bathroom Setup Stall or Tub Stall Tub Curtain or Door Curtain Door Walk-in or Ledge Walk-in Ledge Ledge Height (Inches)Please enter a number from 1 to 36.Does the bathroom have: Grab bars Flex shower hose Shower seat Tub transfer bench What type of equipment do you presently have? (Indicate if items were purchased or through insurance) Hospital Bed (Insurance) Hospital Bed (Out of Pocket) Standard wheelchair w/ big wheels (Insurance) Standard wheelchair w/ big wheels (Out of Pocket) Front wheel walker (no seat) (Insurance) Front wheel walker (no seat) (Out of Pocket) Single point cane (Insurance) Single point cane (Out of Pocket) Quad cane (Insurance) Quad cane (Out of Pocket) Rollator (4 wheels with seat) Transport wheelchair Bedside commode Other (list below) Other Equipment:Please list any other equipment you have. Prior to hospital admission, describe your ability to:Walk With no device Used device (List Below) Can only walk with assistance Cannot walk What device assisted you in walking?Go to the toilet Cared for self completely Needed some assistance Needed total assistance Continence- Bladder Continent Incontinent Continence- Bowel Continent Incontinent Dress yourself Cared for self completely Needed some assistance Needed total assistance Bathe yourself Cared for self completely Needed some assistance Needed total assistance Did you have help at home w/Daily care needs? If so who assisted:Preference with Equipment Company?If yes, please describe.Preference with any Medicare approved Home Health Agency for Therapy after discharge?If yes, please describe.Has a Medicaid application been submitted? Yes No Medicaid application, when and who submitted the application?Do you need information about Medicaid? Yes No Preferred Pharmacy:Primary Care Physician:Therapy goal:Discharge Plan A and B:Long-Term Care Insurance (LTCI) policy: Yes No Do you own your property? Yes No Do you need 24 hour supervision at home? Yes No How much can you afford for long-term care every month?Please enter a number from 0 to 99999.
