Nursing Home Admission Pre-Screening

Nursing Home Admission Pre-Screening — Form Fields

This healthcare template includes 10 fields. Complete a pre-screening form to assess suitability for nursing home or long-term care facility admission. Free to customize and use on ZenBuild.

• Resident Full Name (text, required)
• Date of Birth (text, required)
• Contact Person Name (text, required)
• Contact Email (email, required)
• Contact Phone (text, required)
• Level of Care Needed (dropdown selection, required) — options: Skilled nursing, Custodial/personal care, Memory care, Rehabilitation, Respite care
• Current Functional Limitations (checkboxes, required) — options: Mobility, Continence, Feeding, Dressing, Bathing, Cognition/memory
• Primary Diagnoses (long text, required)
• Does Resident Have a Feeding Tube or Ventilator? (multiple choice, required) — options: Yes, No
• Behavioral or Safety Concerns (long text, optional)