CONTACT DETAILS
FINANCIAL DETAILS
EMERGENCY CONTACT INFORMATION
MEDICAL INFORMATION
Do you have any allergies or dietary restrictions? If so, explain.
Are you currently experiencing fever, dry cough, covid or flu-like symptoms? If so, explain.
Do you have any chronic medical issues we should be aware of? (i.e. diabetes, copd, etc) If so, explain.
Do you have any special medical equipment? If so, explain.
RESIDENT FIT DETAILS
Can you walk independently? Are you able to travel stairs? If no, explain.
Can you participate in household cleaning and chores? If no, explain.
Can you bathe and dress yourself? If no, explain. Do you bathe every day? If no, explain.
Do you have any issues with bladder control? If yes, explain.
Do you have any regular medical appointments? If so, explain.
Do you smoke or vape? If so, do you understand these activities are NOT permitted inside the house and only in the designated outside area?
Do you work or volunteer anywhere? Explain any work during curfew hours (10pm - 6am)
What is your normal bedtiime?
List any disliked/favorite foods, activities, you enjoy, concerns you may have living with a roommate, and anything else we should know.
PROBATION DETAILS
Are you on probation/parole? If yes, which one? Please provide details.
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