Admission Form · Divya Vriddhashram by Nyagrodha Foundation

1

Elderly person details

About the person seeking admission.

Personal information

Full name *

Date of birth *

Age (filled in for you)

Gender *

Marital status *

Anniversary date (if applicable)

Phone number *

Residential address *

City or town *

State *

Pin code *

Address proof

Type of address proof *

Address proof number *

Date of issue or validity

Which category are you applying under?

Free, destitute or poorNeeds a general memo from the police department and an income certificate. Paid, monthly or donationWe will discuss room type and fees on a call.

2

Health information

So the nurses know what to watch for from day one.

Current vital signs

Blood pressure, systolic (mmHg)

Blood pressure, diastolic (mmHg)

Last recorded on

Blood sugar, fasting (mg/dL)

Post-meal sugar (mg/dL, if applicable)

Recorded on

Height (cm)

Weight (kg)

Current medications

List all current medications *

Medical history

Has the elder been diagnosed with any of these?

Details of medical conditions

Allergies

Food allergies, if any:

Medicine or drug allergies

Other allergies or sensitivities

3

Special preferences and dietary needs

The small things that make a place feel like home.

Dietary preferences

Dietary preference *

Mobility status *

Food likes (preferred foods)

Food dislikes (foods to avoid)

Special care and lifestyle

Any special requirements or preferences

4

Guardian or admitting person

Who we call, and who signs.

Primary guardian information

Full name *

Relationship to the elder *

Phone number *

Email address (optional)

Residential address *

City or town *

Pin code *

Type of address proof *

Address proof number *

Date of issue or validity

Secondary contact person (optional)

Full name

Relationship to the elder

Phone number

Employment and financial information

Employment status *

Designation or position

Organisation or company name (if employed)

Work phone number

Monthly income range *

Payment method for care fees *

5

Additional information and consent

A few last details, then you are done.

We are committed to protecting your privacy. Everything provided in this form is kept strictly confidential and used only for care-related purposes.

Reason for admission

Medical provider information

Primary physician name

Physician contact number

Consent and declarations *

Guardian signature *

Date of application *

Additional notes or comments

We will call you within two days of receiving this.