Admission Application Application Form There is no fee to apply and no deposit required. You will receive an email confirmation of your submission. Application Potential Resident Information:PrefixName(Required) First Last Preferred Name First This field is hidden when viewing the formBirth Date(removed)Birth Date MM slash DD slash YYYY Marital StatusGenderFemaleMaleCurrent Address Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code Person completing this form:Name First Last Relationship To Potential ResidentAddress Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code Your Email Address(Required) Email Address Confirm Email Address Your PhonePotential Resident Information:Does the person have a memory problem? Yes No If Yes, for how long?Has this condition been evaluated? Yes No If Yes, evaluation was performed by:DiagnosisPrimary Care PhysicianOther Medical DiagnosisCurrent MedicationsPrimary CaregiverRelationship To Potential ResidentWhat are the current living arrangements? Independently at home With family At a care facility Other If at a care facility, where?If other living arrangements, please describeWhat supportive services are provided?Describe the person's cognitive abilities in the following areas:MemoryJudgementLanguage (Speaking & Comprehension Skill)Responsive to requests / instructionsDescribe the amount of assistance required in the following activities:e.g., independent, cueing required, assistance, total assistanceDressingMealtimesCurrently on special diet ordered by physician? Chopped Fine chopped Puree Other If other special diet, please describeThickened liquids? Yes No If Yes, please describe liquid thiknesse.g., nectar, honey, puddingBathingToiletingIs the person continent? Yes No If NO, please describe assistance requiredAble to walk independently? Yes No Requires Assistance Assistive devices used? Cane Walker Wheelchair Is the person diabetic? Yes No How is it managed? Diet Oral Medications Insulin Injections Other If Other, how is it managed?This field is hidden when viewing the formHow is it managed?(removed) Diet Oral Medications Insulin Injections Other Does the person wander?e.g., paces, “wants to go home”, times most likely to wander, etc.Describe any challenging behaviors?e.g., verbally/physically aggressive, resistive to care, etc.Sleep habits or problems?Describe the person's personality before the illness and today:The following words may be helpful: content, extrovert, friendly, happy, independent, introvert, reserved, sad, serious, suspicious, timidPersonality before the illnessPersonality todayDescribe a typical day for this personDescribe a typical night for this personPower of AttorneyHas a durable medical power of attorney been designated? Yes No NamePhoneHas a durable financial power of attorney been designated? Yes No NamePhoneHas an advance directive or living will been completed? Yes No Which locations are preferred?Check all that apply Bayside Nu'uanu Pali What types of room are preferred?Check all that apply Semi-Private Private How soon is placement desired? Immediate - within 30 days Soon - within 3 months Within one year Long Term - more than one year How did you hear about Hale Kū‘ike?Healthcare Professional (e.g., Physician, Social Worker, etc.)Friend / FamilyReferral agencyOnline SearchTV adOtherPlease specify the Healthcare Professional (e.g., Physician, Social Worker, etc.)Please specify the friend or familyWhat Referral Agency? Elite Care Finders Kupuna Care Connection Kupuna Care Pair Nurse Home Partners CareSift What TV channel? KHON2 Cable TV Streaming TV If Other, please describe: View Our Locations Pali Bayside Nu‘uanu
