IJN Residential Skilled Nursing Services

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Pre-Admissions Form Email Address: Phone: ____________________________ Client: ________________ Date of Birth: ________________ Current Diagnosis: ___________________ Medical Diagnosis: ___________________ Pertinent Medical History: ______________________________________________________________________________________________________ Is skin in tact? _____ If currently in the Hospital, Why: ________________________________________________________________________________________________________________________________________ Medicaid #: __________________ Medicare #: __________________ Continence Status Bladder? ______ Bowel? ________ Ambulation Status Independently? _____ or With Device____, (check which applies) Cane ___ Walker ____Wheelchair ____ Transfer Assistance Required? ____ (check which applies) ___Tub ___Wheelchair ___Toilet ___ Bed Hear (with or without device) _____ Last TB test Date____ Results Last Physical Date ______________ Where ___________________________ [THIS DOCUMENT COMES DIRECTLY TO OUR OFFICES FOR A MORE EXPEDITED APPROACH, YOU MAY CALL US DIRECT: (404) 447-0800]

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item 1 Immediate Service Required (within 24 Hours)
item 2 Non Emergency Move in (with 1 week)
item 3 Future Move In (after 30+ days)