ASSISTED LIVING RESIDENCE
RESIDENT PERSONAL DATA FORM
New York State Department of Health
Division of Assisted Living
Resident’s Name: __________________________________ Facility Name: ____________________________________
ADMISSION / DISCHARGE INFORMATION
Date of Admission: ______________________________________ County:_________________________
Admitted from:
 Own Home  Hospital  NH  OMH  Other (specify): _________________________________
Address Admitted from (Street, City, State, Zip): ________________________________________________________________
Discharge Date: _________________________ Discharge to:
 Own Home  Hospital  NH  OMH
 Other (Specify): ______________________________________
Address Discharged to (Street, City, State, Zip Code): ___________________________________________________________
Reason for Discharge:______________________________________________________________________________________
__________________________________________________________________________________________________________
SECTION 1:
PERSONAL DATA
Date of Birth: _______/_____/______ Gender:
Month
Day
Year
M F
NOTIFY IN CASE OF EMERGENCY
Name ________________________________________
Relationship ___________________________________
Home: ________________ Work:_________________
Cell Phone:_____________ Other:_________________
Address ______________________________________
City ___________________ State _____ Zip ________
Status:
Married Single Divorced Widowed Partner
OTHER HEALTH CARE PROVIDERS
Name _________________________________________
Specialty ______________________________________
Phone: __________________ Fax:__________________
Address _______________________________________
City ____________________ State _____ Zip _________
Name _________________________________________
ATTENDING PHYSICIAN
Name __________________________________________
Specialty _______________________________________
Phone: __________________ Fax:__________________
Address ________________________________________
Address ________________________________________
City ____________________ State _____ Zip _________
City _____________________ State _____ Zip ________
Phone:_________________ Fax:____________________
Name _________________________________________
OTHER HEALTH CARE PROVIDERS
Specialty ______________________________________
Name _________________________________________
Phone: __________________ Fax:__________________
Specialty ______________________________________
Address _______________________________________
Phone: __________________ Fax:__________________
City ____________________ State _____ Zip _________
Address _______________________________________
Name _________________________________________
City ____________________ State _____ Zip _________
AREA HOSPITAL / CLINIC OF CHOICE
Specialty _______________________________________
Name _________________________________________
Specialty _______________________________________
Phone: __________________ Fax:__________________
Name __________________________________________
Phone: __________________ Fax:__________________
Address_________________________________________
Address ________________________________________
Additional Information:____________________________
City _____________________ State _____ Zip ________
________________________________________________
Address ________________________________________
________________________________________________
City _____________________ State _____ Zip ________
DOH-4397 Part A (03/08) Rev. 09/12
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ASSISTED LIVING RESIDENCE
RESIDENT PERSONAL DATA FORM
New York State Department of Health
Division of Assisted Living
Resident’s Name: __________________________________ Facility Name: ____________________________________
SECTION 1: PERSONAL DATA Cont.:
HEALTH INSURANCE
PHARMACY
Insurer _________________________ID # _____________
Pharmacy(ies) _____________________________________
Medicaid No. _____________________________________
__________________________________________________
Medicare No. _____________________________________
Phone ____________________Phone ___________________
Prescription Drug Plan (if any) ________________________
Address(es) ________________________________________
Plan ID # _________________________________________
__________________________________________________
Other Health Care Coverage ________________________
City ______________________ State _______ Zip_________
_________________________________________________
SECTION 2:
PERSONAL BACKGROUND
Wishes to be addressed as: ____________________________________________________________________________________
Address (if different from ALR): _________________________________________________________________________________
Resident’s Representative: ______________________________
Relationship: __________________________________________
Significant Other:____________________________________
Address:______________________________________________
Relationship:________________________________________
______________________________________________
Address:___________________________________________
Home_____________________________
___________________________________________________
Work _____________________________
Phone:
Phone:
Cell _____________________________
Home____________________________
Work____________________________
Cell______________________________
Resident’s Representative: ______________________________
Relationship: __________________________________________
Significant Other:___________________________________
Address:______________________________________________
Relationship:______________________________________
______________________________________________
Address: __________________________________________
Home_____________________________
__________________________________________________
Work _____________________________
Phone:
Phone:
Cell _____________________________
Home _________________________
Work _________________________
Cell _________________________
Residential Background (born/raised, lived most of life):__________________________________________________________
__________________________________________________________________________________________________________
Occupational/Educational Background: _______________________________________________________________________
_________________________________________________________________________________________________________
Religious Affiliation (if any): _______________________ Place of Worship: ___________________ Phone: _______________
DNR:  Yes  No
(Name)
Power of Attorney:  Yes  No _________________________________________
Living Will: Yes  No 
(Name)
Burial Instructions: _________________________________________________________________________________________
Health Care Proxy:
Yes
 No __________________________________________
___________________________________________________________________________________________________________
DOH-4397 Part A (03/08) Rev. 09/12
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