Life Care Home Orientation

Orientation Packet
Personal Information
First Name*
Middle Name
Last Name*
Mother's Maiden Name*
Street Address:*
Apartment/Suite #:
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City:*
State:*
Zip:*
Mobile Phone Number:*
Home Phone Number:
Email Address:
example@example.com
Date of Birth:*

MonthDayYear
Social Security #:*
Terms and Conditions:*

I have reviewed the above document and agree to the Terms and Conditions
Applicant Signature*

Clear

	No	Yes
Weakness
Unexplained Fatigue for more than 3 weeks
Lack of Appetite
Unexplained Weight Loss
Low Grade Fever
Unexplained Fever, Chills, or Drenching Night Sweats
Persistent Shortness of Breath
Persistent cough for more than 3 weeks
Blood streaked sputum
Clear, Yellow, or Dark Sputum
Coughing Up Blood
Chest Pain
Have you ever been diagnosed with active TB disease?
Have you been treated with medication for TB or for a positive TB test?
Have you ever been diagnosed with latent TB infection or had a positive skin test or a positive blood test for TB?
Have you ever lived in a country with a high TB rate?
Is your immune system compromised due to a virus or medication?
Have you recently had close contact with someone who has had TB disease?

Personal Information