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Date of initial contact
Club Location
Date
Month
Day
Year
Primary Caregiver
Relation
Phone
Email
Where did you learn about OFC?
Potential Member
Name
Age
Gender
Partner/ Marital Status
Partner Name/Relation
Other care providers/relation
Lives with
Location
How Long
Diagnosis
When diagnosed?
How long has care been needed?
Medications
Follow up:
Member administers own medication?
Mobility equipment
Incontinence products
Assistance needed (toilet, eating, other cues)
Medical History (stroke, diabetes, depression, anxiety, etc.)
Veteran?
Yes
No
LTC Insurance?
Yes
No
POLST?
Yes
No
Date of First Visit:
Date Registration Form sent
Follow up (1) :
Month
Day
Year
Time
:
Hours
Minutes
AM
Follow up (2):
Month
Day
Year
Time
:
Hours
Minutes
AM
Follow up (3):
Month
Day
Year
Time
:
Hours
Minutes
AM
Submit
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