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									Applicant’s Name ___________________________________________________________________Date _________________

                                                     Saint Rose’s Home
                                                      71 Jackson Street
                                                    New York, NY 10002
                                         Tel (212) 677-8132     Fax (212) 982-3485

                               APPLICATION AND PRE-ADMISSION FORM
                                         Please read all information carefully.
                 All questions must be answered before the application can be reviewed and processed.

Requirements for admission to Saint Rose’s Home

Documented proof of a diagnosis of incurable cancer is required. This may be a Pathology Report, a CAT scan, a
Biopsy Report, or other requested information.

Saint Rose’s Home is a free home for those who are financially unable to afford nursing care elsewhere. This means
that the resident does not have assets that would cover the cost of nursing care.

                                     Saint Rose’s Home accepts no payment of any kind,
                               including Medicare, Medicaid, private insurance or private pay.
                      This policy applies while the patient resides at the Home and after they have died.
                                        Financial need is a requirement for admission.

Patients and families must be informed that the care provided by Saint Rose’s Home is palliative, not curative. All
treatments must be completed before the patient is accepted. Medications and ancillary orders will be prescribed by
our physicians.

Do Not Resuscitate – Because only persons with incurable cancer are admitted to Saint Rose’s Home, and because
Saint Rose’s Home provides only palliative care, all patients must submit a valid “Do Not Resuscitate” (DNR) order
prior to admission.

Palliative care is a concept of care which employs medical and nursing care as well as specific ancillary services, when
indicated, whose primary objective is the comfort and overall well-being of the incurable/terminal individual. No
treatment is employed which would overburden the individual, yet full support is offered for basic physical needs as
well as spiritual, psychological, and emotional needs. Individuals, while experiencing similar diagnoses, may have
different needs or symptoms associated with their disease and secondary diagnoses; hence, personalized medical or
nursing plans of care based on individual needs and symptoms are developed.

Saint Rose’s Home complies with all applicable federal, state, and local civil and human rights laws with regard to
employment and provision of services. Patients are welcome regardless of age, color, creed, sex, national origin,
sexual orientation, handicap, or marital state.

I AM AWARE OF AND ACCEPT THE POLICIES STATED ABOVE.
Signature of patient/responsible person required for admission.

Signature ___________________________________________________________________Relationship _____________________________

Name (print) ____________________________________________________________Home Phone _________________________________

Address ________________________________________________________________Work Phone _________________________________


Revised 7/2003                                                                                                         1
NAME ________________________________________________________________________________________________
                 Last                                     First                                 Middle
ADDRESS____________________________________________________________________________________________________________________
                 Street                                                        City                          State                     Zip Code



DATE OF BIRTH________________________________ BIRTHPLACE____________________________________________

FATHER’S NAME __________________________________ MOTHER’S NAME ____________________________________
                          First                  Last                                               First                     Maiden


AGE ____________ MARITAL STATUS ___________________________ RELIGION _______________________________

SOCIAL SECURITY __________________________________VETERAN _________________________________________
                                                                                         Branch of Service
LIFETIME OCCUPATION ________________________________________________________________________________

HIGHEST LEVEL OF EDUCATION _________________________________AMBULATORY?________________________

LIVED ALONE?______________________________HEIGHT ________________________WEIGHT___________________

ADMITTED FROM ______________________________________________________________________________________

LOCATION OF ABOVE FACILITY ________________________________________________________________________

IF ADMITTED FROM HOME, DATE OF MOST RECENT HOSPITALIZATION ___________________________________

*******************************************************************************************************

FAMILY MEMBERS OR RESPONSIBLE PERSONS
Please indicate if the person listed has Power of Attorney or other special legal relationship to the patient.

1. ____________________________________________________________________ ________________________________
       Name                                             Relationship                                         Home Telephone
  ____________________________________________________________________ ________________________________
       Address                                                                                               Work Telephone
2. ____________________________________________________________________ _______________________________
       Name                                             Relationship                                         Home Telephone
  ____________________________________________________________________ _______________________________
       Address                                                                                               Work Telephone
3. ____________________________________________________________________ _______________________________
       Name                                             Relationship                                         Home Telephone
 ____________________________________________________________________                         _______________________________
       Address                                                                                               Work Telephone




Saint Rose’s Home Use Only

Admission Date _____________________                              Admission Number __________________________

Coming by _________________________                               Room Assignment ___________________________




Revised 7/2003                                                                                                                                    2
                                                 NURSING ASSESSMENT

Name _____________________________________________________________________________Age________________

1. Present Mental Status:

             Alert _____    Disoriented ______    Noisy ______     Depressed ______       Abusive _______
          Oriented _____       Anxious ______      Quiet ______    Withdrawn ______ Noncompliant _______
     Decisions Consistent & Reasonable ______  Lethargic ______    Suspicious ______  Unresponsive_______
Comments _______________________________________________________________________________________________

2. Activity/Mobility                                         Transfers            Locomotion
        Dependent for all position changes ______    Full Assist ________           Gerichair ______    Other ________
                                   Bedfast ______ Limited Assist ________          Wheelchair ______
                             OOB to chair ______    Supervision ________              Walker ______
                               Ambulatory ______    OOB ad lib ________                 Cane ______

3. Diet/Nutrition
        Type of Diet ____________________________________________________

        Chewing or Swallowing Problems ___________________________________

        NPO ___________________________________________________________

        Artificial Nutrition (PEG, TPN, PPN, etc.) or Hydration (IV) explain __________________________________________
        __________________________________________________________________________________________________

        Height ________________ Weight _________________ Usual Weight Prior to Illness _______________

4. List of All Allergies ______________________________________________________________________________________

5. Communication
      Language Spoken: English _____________ Other (specify) _______________________________
      Aphasia ________________ Speech Slurred or Garbled _____________ Noncommunicative ______________________

6. Special Needs/Appliances/Equipment
        Oxygen (mode of delivery and l/min) __________________      Incontinent of Urine __________________________
                Tracheostomy (size & make) __________________             Foley Catheter _________________________
                                   Suction __________________        Incontinent of Feces _________________________
                                 Humidifier _________________           Ostomy (specify) _________________________

        Wound Care (explain in detail size, origin, procedure) ____________________________________________________
        ________________________________________________________________________________________________
        ________________________________________________________________________________________________

        Other Issues/Needs ________________________________________________________________________________
        ________________________________________________________________________________________________

7. Restraints (describe and explain ) _________________________________________________________________________
   ____________________________________________________________________________________________________

8. Smoking       Currently smokes ____________       Packs per day _________________

9. History of Alcohol or Drug Abuse (explain) ________________________________________________________________
   ____________________________________________________________________________________________________

Nurse Signature ________________________________Print Name __________________________ Phone _______________
Revised 7/2003                                                                                                        3
                                                                   MEDICAL SUMMARY

Name ______________________________________________________________________ Age __________

Primary Diagnosis __________________________________________________

Secondary Diagnoses _____________________________________________________________________________________

Primary Site of Malignancy _______________________________________________ Date of Onset _____________________
             A Pathology Report and/or appropriate scans and lab results supporting the diagnosis must be attached.

Presenting Symptoms _____________________________________________________________________________________

Prognosis/Stage of Illness __________________________________________________________________________________

Brief Medical Summary and Course of Treatment _______________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________


TB screen         PPD (required) ____________________________________________________________
                                        Results                   Date

                  Chest x-ray (attach report or write) _____________________________________________________
                                                           Results                   Date

Infectious Diseases over the past 90 days _______________________________________________________________________

Current Medications _______________________________________________________________________________________




History of Mental Illness (explain) ____________________________________________________________________________

________________________________________________________________________________________________________


           Stamp, type, or print the the name, address, and telephone
         Please stamp, type, or printname, address, and telephone number
           of the physician here.
         number of the physician.




                                                                           _________________________________________________
                                                                           Signature of Physician              Date


Revised 7/2003                                                                                                                 4
Revised 7/2003   5

								
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