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Mon-Fri: 9am–5pm
(847) 784-6000
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About
Programs & Services
Lifelong Learning
Events & Education
Amenities
Support Us
Blog
Contact
Mon-Fri: 9am–5pm
(847) 784-6000
Join
Donate

About
Programs & Services
Lifelong Learning
Events & Education
Amenities
Support Us
Blog
Contact
Mon-Fri: 9am–5pm
(847) 784-6000
Join
Donate

Pub Night 2025

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HOW Demographics Form

Home » Programs & Services » Memory Care Programs » House of Welcome Adult Day Program » HOW Demographics Form

Fill out the form below or, click here to download, fill out, and email to us at: how@nssc.org.

Demographics/Health History

Application Date

Person Completing Application

Relationship

Participant Demographics

First Name

Last Name

Preferred Name / Nickname

Address

Date of Birth

Primary Phone

Participant Gender

Female Male Non-Binary Transgender-Female Transgender-Male Not Disclosed

Participant Living Arrangement

Alone Spouse Adult Child(ren) Caregiver Other

Race (choose up to two)

Asian Black/African American Hawaiian/Pacific Islander Native American/Alaskan White

Ethnicity

Hispanic/Latino Not Hispanic/Latino

Primary Language Spoken

Other Language Spoken

Driving Status

Still Driving No Longer Drives Never Drove

Spouse/Partner (if any)

Name

Address

Primary Phone

Relationship

Years Together

Occupation

Retired

Yes No

Primary Caregiver (if not spouse/partner)

Name

Relationship

Address

Primary Phone

Other Emergency Contact (local)

Name

Relationship

Address

Primary Phone

Advance Directives

Does applicant have any of the following:

Power of Attorney for Health Care

Yes No

Name

Relationship

Address

Primary Phone

Power of Attorney for Property

Yes No

Name

Relationship

Address

Primary Phone

POLST (Practitioner Order for Life-Sustaining Treatment form) or DNR (Do Not Resuscitate Order)

Yes No

Health Insurance Info

Social Security Number

Medicare Number

Medicare Part

A B D

Name of any additional health insurance providers:

Address

Phone

Long-term care insurance?

Yes No

If yes, Carrier:

Primary Care Physician Information

Primary Care Physician

Hospital system affiliation

Phone

Date of Last Appointment

Specialist Information

Specialist #1

Physician Name

Specialty

Hospital system affiliation

Phone

Specialist #1

Physician Name

Specialty

Hospital system affiliation

Phone

Medical Information

Preferred Hospital

Last hospitalization and reason

Memory

When did you first notice memory problem?

Date of diagnosis, if any:

Cause/diagnosis for memory loss:

Person’s understanding of diagnosis

Please describe any significant changes in person’s memory, language skills and behavior

Medications

Please list all prescription and over-the-counter, including vitamins and supplements (Name, Dosage mg/frequency taken, and reason for taking). One per line.

Functional Info

Hearing

Hearing Loss

Right ear Left ear Both ears None

Hearing Aids

Right ear Left ear Both ears None

Comments

Vision

Vision Loss

Right eye Left eye Both eyes None

Glasses / Contact Lenses

Yes No

Comments

Mobility

Walks Independently

Yes No

Needs Assistance with walking / transferring

Yes No

Uses assistive equipment?

Cane Walker Wheelchair None

Toileting

Indicate level of toileting needs:

Independent Needs some assistance Needs complete assistance Incontinent of urine Incontinent of bowel Uses incontinence products

Allergies/Dietary

Please list all allergies (food, medication, animal, and/or environmental) and a description of the person’s reaction

Please list any dietary restrictions

Other Significant Info

Please share anything else you would like us to know, including trauma, significant losses, family dynamics, etc.:

Reach Out Today.

Take the first step toward a more enriching life with NSSC. We look forward to welcoming you!

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North Shore Senior Center does not discriminate against any person served, person employed, or person seeking employment based on age, sex, race, color, disability, ethnicity, national origin, genetic information, religious tradition or spiritual practice. If you feel that you have been discriminated against, call the Senior Help Line at 800.252.8966 or 888.206.1327 (TTY).

Funds in whole or in part for our programs are provided by AgeOptions.