Section 1: Personal Information
1. Full Name: _______________________________________________Nickname _________________________

2. Date of Birth: _______________________________________________
3. Gender: _____________________________________________________
4. Address: ____________________________________________________
- City: ______________________ 

State: __________ Zip Code: ______________
5. Phone Number: ______________________________________________
6. Email Address: _______________________________________________

Section 2: Emergency Contact Information
1. Name: _______________________________________________________
2. Relationship: _______________________________________________
3. Phone Number: ______________________________________________
4. Alternate Phone Number: ______________________________________

 

Section 3: Medical Information

1. Do you have any existing medical conditions? (Yes/No)
If yes, please specify: ________________________________________

2. Are you currently taking any medications? (Yes/No)
If yes, please list: ____________________________________________

3. Do you have any allergies? (Yes/No)
If yes, please specify: ________________________________________

4. Name of Primary Care Physician: _____________________________________________
Phone Number: _____________________________________________

5. Insurance  (Yes/No) 

If yes, please state company 

______________________________________________

Company ID # 

______________________________________________

 

6. Is it anything that will prevent you from not passing a background? 

______________________________________________

 

 

Section 4: Living History
1. Current Living Situation:
- [ ] Independent Living
- [ ] With Family
- [ ] Assisted Living Facility
- [ ] Other (please specify): ________________________________

2. Have you lived in an assisted living facility before? (Yes/No)
If yes, please provide details: ________________________________

Section 5: Preferences and Interests
1. What are your hobbies and interests?
_____________________________________________________________

2. Are there specific activities you would like to have access to at Pinky Promise Creators?
_____________________________________________________________

3. Do you have any pets? (Yes/No)
If yes, please specify type and size: ___________________________

Section 6: Additional Information
1. What are your expectations from living at Pinky Promise Creators?
_____________________________________________________________

2. Are there any special accommodations you may require?
_____________________________________________________________

3. Is there any other information you would like to share with us?
_____________________________________________________________

Signature: _____________________________________
Date: ______________________________________