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The Personal Profile And Survey / Communications (Armed Forces Retirement Home)

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Country of origin: US
File type: PDF

U.S.A. forms for Armed Forces Retirement Home

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ARMED FORCES RETIREMENT HOME
Personal Profile and Survey
Name: ____________________________________ Anticipated arrival: ______________
For Employee Use
ⒼⓌ ⓐ
Report: ____________
Page | 1
Prior Versions No Longer Valid
PPS 02-2021
Non-Smoker
Male
Single
Separated
Smoker
Female
Divorced
Widowed
1. In which of the Armed Forces were you a member? __________________________________________
2. Any Military Associations or Community service? __________________________________________
3. What was your primary military profession or job? __________________________________________
4. Did you have any civilian or other career? __________________________________________
5. Do you have any hobbies or interests? __________________________________________
6. What is your educational background? Do you have any of the following types of experience?
High School Community/Trade School College/University Post-Graduate Education
7. How does your health compare with others your age?
Very healthy Fairly healthy Average health Below average health
8. Describe what your current living arrangements are:
Own Home Rent/Lease Retirement Community Living with family member
9. Do you currently live in a:
House Townhouse Apartment Condo Mobile Home
Other type of home: ________________________________________________________________
10. Which of the following factors are prompting you to apply for residency at this time? (select three)
Difficult to maintain Lack of security Healthcare needs Want community
High cost of living Need entertainment Loneliness Ready to downsize
11. Do you have any denominational/religious preferences? _______________________________________
12. Have you ever applied to AFRH or been a resident here? Yes No
13. When determining where you want to live, how important are the following factors?
Extremely
Important
Very
Important
Somewhat
Important
Not
Important
Need to be independent
Want to be near friends
Want to live near my family
Ease of access to medical care
Ease of access to shopping
Want to lower cost of living
Veteran friendly community
Want to live in a different climate
ARMED FORCES RETIREMENT HOME
Personal Profile and Survey
Name: ____________________________________ Anticipated arrival: ______________
Page | 2
Prior Versions No Longer Valid
PPS 02-2021
Location
Onsite Amenities
Activities/Recreation Therapy
Planned Outings/Trips
Onsite Dental/Vision Services
Onsite Medical Clinic/Pharmacy
Transportation to medical care
Meal Service (3 daily meals)
Ability to Age in Place
Physical/Occupational Therapy
Social Activities/Services
Cleanliness of facility
Private room & bathroom
Unit features/style
Laundry room (no charge)
Staff (helpful, friendly)
Affordability of advanced care
Local attractions
14. Please let us know which of the following amenities/services offered at AFRH you find appealing
Fitness Center
Woodworking Shop
Art Studio Spaces
Table Tennis
Swimming Pool
Library
Golf Course
Puzzle Room
Bowling Alley
Resident Bar & Lounge
Leatherworking
Bocce Ball Court
Ceramics Studio
Shuffleboard
Fishing Pond
Horseshoes
Computer Center
Theater / Media Center
Bingo
Corn-Hole Toss
Canteen / Café
Art or Music lessons
Auto Hobby Shop
Walking Trails
Chapels
Military Celebrations
Game Rooms
Clubs/ Club Room
Exercise classes
Personal nutritionist
Podiatry Services
Counseling services
Dances/Socials
Volunteer opportunities
PX/NEX
Trips to casinos
Bible Study
Education opportunities
Beach Access
Salon/Barber
ARMED FORCES RETIREMENT HOME
COMMUNICATIONS - PRIMARY APPLICANT
Name: ____________________________________ Anticipated arrival: ______________
For Employee Use
ⒼⓌ ⓐ
Report: ____________
Page | 3
Prior Versions No Longer Valid
PPS 02-2021
FAMILY PROFILE AND CONTACT INFORMATION
Please provide your next of kin or emergency contact information.
Relationship
Full Name (include both middle & maiden names as applicable)
*name is required for identification purposes & record keeping
Father*:
Deceased
Mother*:
Deceased
Spouse:
Deceased
Relationship
Name
Address
Contact information:
Child 1
Child 2
Child 3
(attach a list if more space is needed)
COMMUNICATIONS:
You may decline or limit permission for AFRH to speak with persons other than yourself, if you wish. To be eligible for
admission you must be independent and have the capacity to manage your own personal affairs. If it is acceptable to
you that we speak with members of your family or other persons inquiring information on your behalf, please let us
know with whom you will allow us to communicate during the application process.
The name(s) listed below are family members, friends, or representatives to whom I grant permission for the Armed
Forces Retirement Home to communicate regarding my application, finances, and/or healthcare. Please indicate any
legal representatives (i.e.: Power of Attorney, Guardian, Durable Power of Attorney for Healthcare or Finance, etc. ).
Relationship (personal/legal)
NAME
CONTACT INFOMATION
Please indicate any limitations to this permission or specific information that you do not wish for AFRH to discuss:
If you are granting/limiting communication with others than yourself, please sign here:
Date
None
CLEAR p. 3-4
ARMED FORCES RETIREMENT HOME
COMMUNICATIONS - COAPPLICANT (if applicable)
Co-Applicant: ____________________________________ Anticipated arrival: ______________
Page | 4
Prior Versions No Longer Valid
PPS 03-2021
FAMILY PROFILE AND CONTACT INFORMATION
Please provide your next of kin or emergency contact information.
Relationship
Full Name (include both middle & maiden names as applicable)
*name is required for identification purposes & record keeping
Father*:
Deceased
Mother*:
Deceased
Spouse:
Deceased
Relationship
Name
Address
Contact information:
Child 1
Child 2
Child 3
(attach a list if more space is needed)
COMMUNICATIONS:
You may decline or limit permission for AFRH to speak with persons other than yourself, if you wish. To be eligible for
admission you must be independent and have the capacity to manage your own personal affairs. If it is acceptable to
you that we speak with members of your family or other persons inquiring information on your behalf, please let us
know with whom you will allow us to communicate during the application process.
The name(s) listed below are family members, friends, or representatives to whom I grant permission for the Armed
Forces Retirement Home to communicate regarding my application, finances, and/or healthcare. Please indicate any
legal representatives (i.e.: Power of Attorney, Guardian, Durable Power of Attorney for Healthcare or Finance, etc. ).
Relationship (personal/legal)
NAME
CONTACT INFOMATION
Please indicate any limitations to this permission or specific information that you do not wish for AFRH to discuss:
If you are granting/limiting communication with others than yourself, please sign here:
Date
None
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Completed 21 June 2021

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