IHAC Application for Services

Medical Information
Present General Practioner

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Last Appointment
Present Dentist

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Current Medications
Please list any current medications, dosage, time of administration and for what reason.
Prescribing Doctor
Prescribing Doctor of Medication
Phone Number
Allergies
Describe any known Allergies
Smoker

YesNo
Alcohol Use

None KnownOccasionallyFrequently
Drug Use Current/History
Describe current or historic drug use and drug of choice
Current On-going Medical Concerns
Previous Conditions That Required Regular Doctor Visits
Previous Conditions that Required Hospitalization
if applicable please include dates
Past Surgeries
if applicable please include dates

	Not Applicable	Independent	Requires Prompting	Requires Assistance
Mobility (Walking, Standing)
Personal Hygiene
Toileting
Menstrual Care
Preparing Meals
Cleaning House/Room
Finance Management
Safety Skills (What to do in case of an emergency, Fire, etc.)

Application for Services