James Milson Village
Page 1 of 3
RESIDENT DETAILS
If no addressograph, please complete the following:
Clinical Record No:
CR 2
Surname:
Given Name:
Date of Birth:
A.
Room No.:
Admission Date:
Other (please specify):
____________________________
PERSONAL DETAILS
Title:

Surname:
_____________________________________________________________________________
Given Name(s):
_____________________________________________________________________________
Date of Birth:
_________________________________________
Country of Birth:
_____________________________________________________________________________
Mr

Aboriginal or Torres Strait Islander:
Marital Status:
Religion:



Mrs
Yes


Ms


Sex:

Male
Female
No



Single
Married
De facto

Widowed
Unknown
Separated
Divorced
_____________________________________________________________________________
Last known residential address:
_________________________________________________________________
street no
street name
_________________________________________________________________
suburb
Telephone number:
Income Status:
state
postcode
_________________________________________________________________





Self Funded


Full aged pension
Part aged pension
Workers’ compensation
Third Party
DVA (type)
_______________________________________
Other: (specify)
_______________________________________
Department of Health Client No:
_________________________________________
Pension No:
_________________________________________
Expiry date: _______________
Medicare no. (incl position no.):
_________________________________________
Expiry date: _______________
PBS Safety Net No:
_________________________________________
Expiry date: _______________
Diabetes Aust No:
_________________________________________
Expiry date: _______________
Australian Hearing Services No:
_________________________________________
Expiry date: _______________
Health Fund:
_______________________________
___________________________________
name
Is the resident on the electoral roll?

No

membership number
Yes
________________________________________
name of electorate
© Copyright: Russell/Hurrell/Andrews
Version 6: January 2012 Review February 2014
CR 2
Page 2 of 3
CR 2
B.
Surname:
Given name:
CR No:
OTHER DETAILS
Attending medical officer:
Name:
_____________________________________________________________________
Address:
_____________________________________________________________________
street no
street name
_____________________________________________________________________
suburb
state
postcode
Contact Numbers: (business hours) _____________________________________________________________________
(after hours)
______________________________________________________________________________
(fax)
______________________________________________________________________________


Funeral arrangements:
Organisation chosen to arrange funeral:
C.
burial
cremation
_______________________________________________________________
ADMISSION DETAILS
Admission date:
Admitted from:
________________________Nursing Home (circle) _________________________Hostel (circle)
_____________________________________________________________________________
Respite: From____________________To_______________________ Pre-entry Leave____________________________
Name of person responsible for payment of accounts:
_________________________________________________
Relationship to resident: _____________________________________________________________________________
Address for postage of accounts:
__________________________________________________________________
street no
street name
__________________________________________________________________
suburb
Contact Numbers:
D.
state
postcode
(home)
______________________________ (work) ____________________________________
(mobile)
__________________________________ (fax)
____________________________________
PRIMARY CARER DETAILS
Who is a ‘person responsible’?
A ‘person responsible’ is not necessarily the patient’s next of kin. A ‘person responsible’ is either:

a guardian who has the function of consenting to medical, dental and health care treatments

or, if there is no guardian:
a spouse or de facto spouse with whom the person has a close, continuing relationship

or, if there is no spouse or de facto spouse
an unpaid carer who is now providing support to the person or provided this support before the person entered residential care

or, if there is no carer:
a relative or friend who has a close personal relationship with the person
Guardianship Tribunal Feb 1998
© Copyright: Russell/Hurrell/Andrews
Version 6: January 2012 Review February 2014
CR 2
Page 3 of 3
CR 2
Surname:
Given name:
CR No:
Primary Carers
Person responsible (1)
Other Contact (2)
Other Contact (3)
Name
Address
Relationship
Telephone (home)
Telephone (work)
Telephone (mobile)
Telephone (fax)
Email address
Does a guardian order exist?
____________________________________________________________________
Date for review of order:
____________________________________________________________________
Name of person completing form:
____________________________________________________________________
(please print)
Signature:
____________________________________________________________________
Date:
____________________________________________________________________
Once completed forward a copy to Accounts Department.
File original for resident’s clinical record
Date Received:
____________________________________________________________________
Date entered into billing system:
____________________________________________________________________
Entered by:
____________________________________________________________________
Signature:
____________________________________________________________________
Once data entered, file copy in resident’s administrative file.
© Copyright: Russell/Hurrell/Andrews
Version 6: January 2012 Review February 2014
CR 2