Legacy House of Bountiful

Telephone: (801)-298-2925
Address: 79 East Center Street
Bountiful, Utah

_______________________________________________ Resident Information

Advanced Directive:
DNR
FULL CODE
Allergies:_________________________________________________________
Name:________________________________________ Admission Date:__________________
Date of Birth:______________________ Age:_________ Room Number:__________________
Social Security Number:__________________ Medicare Number:________________________
Gender: ____Male ____Female
Religion:__________________________________
Veteran: ___________________________ Division___________________________________
Marital Status: ______Married ______Widowed ______Divorced ______Never Married
Spouses Name:________________________________ Spouses Death:__________________
Lived alone prior to entry: ______Yes ______ No

Emergency Contact Information:

Contact 1: Name______________________________________ Phone Number:_____________
Address:____________________________________ Relationship:______________
Contact 2: Name______________________________________ Phone Number:_____________
Address:____________________________________ Relationship:______________
Contact 3: Name______________________________________ Phone Number:_____________
Address:____________________________________ Relationship:______________
Person Responsible for Account: ___________________________________________________
Address: _____________________________________________________________
Phone Number__________________ Email Address:__________________________
Relationship:__________________________________________________________

Medical History:
Past Medical History: ____________________________________________________________
______________________________________________________________________________
Medication Administration: _____Self
____Facility
Assistive Devices: (wheelchair, walker, ect.): ____________________________________________
______________________________________________________________________________
Diet: ________________________________________________________________________
Physician: _____________________________________________________________________
Address: ___________________________________________________________
Phone Number:__________________ Fax Number: __________________________
Outside Agency:_______________________________________________________________
Phone Number:__________________ Fax Number: _________________________
Dentist: _______________________________________________________________________
Mortuary: _____________________________________________________________________

Legacy House of Bountiful

Telephone: (801)-298-2925
Address: 79 East Center Street
Bountiful, Utah

Secondary Insurance: ____________________________________________________________

Adress:______________________________________________________________
Policy Number:________________________________________________________

Race/Ethnicity: _____ American Indian/ Alaskan Native

_____ Black, not of Hispanic Origin
_____ White, not of Hispanic Origin
Language: _________________________________

_____ Asian/Pacific Islander

_____ Hispanic

Lifetime Occupation:____________________________________________________________
Religion:_____________________________ Contact Person:__________________________
Location:____________________________

_______________________________________________________
Employee Signature

__________________
Date