Highlands Community Ministries
Adult Day Health Center
Where Your Family is Family to us.
2000 Douglass Boulevard
Louisville, KY 40205
(502) 459-4887
director@hcmss.org
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* Your name:
* Street Address:
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* Phone (Day): (Evening):
 
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Prospective participants...
 
Do you have someone in mind as a possible participant?
Are you a caregiver for this person?
What is his/her name?
How old is she/he?
What is his/her relationship to you?
If someone referred you to us, who was it?
  (Other):
Other helpful information...
(This information will help us identify any special needs your participant may have.)
 
How is the prospective participant's overall health?
 
Does she/he have any of the following conditions?
Depression Heart Problems
Stroke Incontinence
 
Does she/he have Alzheimer's or Dementia? Is she/he aware of this diagnosis?
Does she/he have a history of wandering?
If she/he has special dietary requirements, what are they?
How well does she/he get around? (Check all that apply) Walks without help
Uses a walker
Uses a wheelchair
Is there anything else we should know?