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Assisted Living Waiver Program Pre-Screening Form
Member Information
First Name
Last Name
Birth Date
Street Address
Street Address Line 2
City
State
Zip Code
Country
Medi-Cal #
Phone Number
E-Mail
Gender Identity
First Name
Last Name
Emergency Contact Phone Number
Emergency Contact Email
Questionnaire
Relationship To Member
Primary Care Doctor
Current Facilities
Skilled Nursing
Assisted Living
Hospital
Home
Assistance Bathing
Yes
No
Assistance Toileting
Yes
No
Assistance Transfers
Yes
No
Is Incontinent
Yes
No
Is Diabetic
Yes
No
Requires Insulin
Yes
No
Has Behavioral Issues
Yes
No
Assistance Personal Hygiene
Yes
No
Assistance Dressing
Yes
No
Assistance Feeding
Yes
No
Assistance Medications
Yes
No
Requires Finger Sticks
Yes
No
Cognitive Issues
Confused
Wandering
Forgetful
Dementia
Alzheimers
None
Other
Cognitive Other
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