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Welcome to Activelife Adult Daycare Inc.
+1 (978) 322-0092
+1 (978) 596-1481
[email protected]
[email protected]
17 Darrin Road, Dracut , MA 01826
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Important Useful Link
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Required Documents
Contact Us
Home
About Us
Services
Activities
Gallery
Important Useful Link
Downloads
Application Forms
PCP Forms
Required Documents
Contact Us
Submit Inquire
Application Forms
Download Form
Step
1
of
6
16%
Application Form for Participants
Application Date
MM slash DD slash YYYY
Referring By
Your Name
First Name
M.I
Last Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
E-Mail
Date of Birth
MM slash DD slash YYYY
Sex
Religion
Place of Birth
Languages Spoken
ID#
Medicaid#
HMO#
SSN#
Medicare#
Other Ins.
Race
American Indians/Alaskan Native
Black/African American
Asian
Asian & White
Asian & Pacific Islander
White-Non-Hispanic
Hispanic/Latino
Marital Status
Never Married
Married
Widowed
Separated
Divorced
Spouse Name
Years Married
Living
Deceased
Living Arrangements
Enter Email
Confirm Email
Living Arrangements
Alone
W/Spouse
W/Children
W/Relatives
Others
Medical Information
Primary Care Physician
Tel#
Address
Address
City
ZIP / Postal Code
Specialist Drs.
Preferred Hospital
Allergy
Current Medication List
Current Medication List
Medication
Dose
Route
Frequency
Add
Remove
Medication Problem
Is Applicant able to sign documents?
Yes
No
Name of Responsible Person
Relationship
Does applicant have Legal Guardian
Yes
No
Name
Address
Tel No.
Has the applicant signed a Power of Attorney?
Yes
No
Name
Address
Tel No.
Emergency Contact: Names & Tel No.
Primary Care Giver Name
Cell
Second Care Giver Name
Cell
Preferred Days of Attendance
1st Choice
Monday
Tuesday
Wednesday
Thursday
Friday
2nd Choice
Monday
Tuesday
Wednesday
Thursday
Friday
Support System Family & Friends
List
Name
Relationship
Contact Frequency
Help Provided
Add
Remove
Community Support Services used by Applicant (check all that apply)
Community Support Services
Meals on Wheels
Senior Center
Senior Transportation
Shopping
Home HHA
Respite
Social Services
Hospice
Visiting Nurse
Others
Education
Grammar
High School
College
Employment History
Special Interests
Current Clubs/Organizations
Preferred Activities
Alone
In-group
Special Talents
Hobbies or Interests
Nutritional Status
Favorite Foods
Special Diet
Appetite
Good
Fair
Poor
Personal Information
DRESSING
Shoes &Stockings
IND
UNABLE ASSIST
UNABLE
Outer Clothing
IND
UNABLE ASSIST
UNABLE
Under Clothing
IND
UNABLE ASSIST
UNABLE
Diet: Dentures
IND
UNABLE ASSIST
UNABLE
Feeds Self
IND
UNABLE ASSIST
UNABLE
PERSONAL HYGINE
Bathing
IND
UNABLE ASSIST
UNABLE
Mouth Care
IND
UNABLE ASSIST
UNABLE
Shampoo, Hair Grooming
IND
UNABLE ASSIST
UNABLE
Shaving
IND
UNABLE ASSIST
UNABLE
Toileting
IND
UNABLE ASSIST
UNABLE
BLADDER FUNCTIONING
Continent
IND
UNABLE ASSIST
UNABLE
Incontinent
IND
UNABLE ASSIST
UNABLE
Catheter Drainage
IND
UNABLE ASSIST
UNABLE
BOWEL FUNCTIONING
Controlled
IND
UNABLE ASSIST
UNABLE
Involuntary
IND
UNABLE ASSIST
UNABLE
Constipation
IND
UNABLE ASSIST
UNABLE
FUNCTIONAL LIMITATIONS
Travels Alone
IND
UNABLE ASSIST
UNABLE
In and Out of Car
IND
UNABLE ASSIST
UNABLE
Walks Unassisted
IND
UNABLE ASSIST
UNABLE
Climbs Stairs
IND
UNABLE ASSIST
UNABLE
Transfers chair to toilet
IND
UNABLE ASSIST
UNABLE
Cane, Crutches, Walker
IND
UNABLE ASSIST
UNABLE
Manages Wheelchair
IND
UNABLE ASSIST
UNABLE
COMMUNICATION ABILITIES
Vision
IND
UNABLE ASSIST
UNABLE
Hearing
IND
UNABLE ASSIST
UNABLE
Speech
IND
UNABLE ASSIST
UNABLE
Do you have memory loss?
Yes
No
Balance
Walking
Standing
Sitting
Signature of Participant/Responsible Person
Date
MM slash DD slash YYYY
