Chapman Valley Manor

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Call Us Today! (785) 922-6525

MAILING ADDRESS

1009 Marshall St. P.O. Box 219

Chapman, Kansas 67431-0219

PHYSICAL ADDRESS

1009 N Marshall St.

Chapman, Kansas 67431-0219

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Pre-Admission Forms

Pre-Admission Forms

Chapman Valley Manor is honored that you would consider us to care for your loved one.

Please fill out this pre-admission form, and one of our team will be in contact with you as soon as possible. We can’t wait to meet you!

CHAPMAN VALLEY MANOR RECORD OF INQUIRY

CHAPMAN VALLEY MANOR RECORD OF INQUIRY

DATE

Last Name of Patient

First Name

Middle Initial

Patient Now At

Diagnosis

Physician

Sex

Age

Date of Birth

Name of Sponsor

Relationship

Address

Work Number

Home Number

Primary Insurance

Number

Other Insurance

Flu Vac Date

Pneumo Vac Date

Covid Vaccine(s)

Infection requiring contact

Mentally Alert

Yes

No

Comments

Confused

Yes

No

Comments

Responsive

Yes

No

Comments

Cooperative

Yes

No

Comments

Noisy

Yes

No

Comments

Ambulatory

Yes

No

Comments

Use Walker

Yes

No

Comments

Use W/C

Yes

No

Comments

Bedridden

Yes

No

Comments

Bed sores

Yes

No

Comments

Medicare only insurance

Yes

No

Comments

Private Pay

Yes

No

Comments

Medicaid

Yes

No

Comments

N.H. Insurance

Yes

No

Comments

Height

Yes

No

Comments

Weight

Yes

No

Comments

Weight

Yes

No

Comments

Pre-screened

Yes

No

Comments

Continent

Yes

No

Comments

Use Catheter

Yes

No

Comments

Feed Self

Yes

No

Comments

Eat at Table

Yes

No

Comments

Regular Diet

Yes

No

Comments

Use Tobacco

Yes

No

Comments

Beauty Shop

Yes

No

Comments

Cell Phone or Room Phone

Yes

No

Comments

Discharge Plan

Yes

No

Comments

DENTURES / PARTIALS

Yes

No

Comments

Comments

Comments

Eyesight

Yes (G)

No (P)

Comments

Comments

Hearing

Yes (G)

No (P)

Comments

Comments

Comments

Speech

Yes (G)

No (P)

Comments

Room Choice

Yes (G)

No (P)

Comments

Swing Bed days used

ANY Hospital stays in the last 90 days, when and where?

Comments

Requested Admission Date

Seeking Information Only

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⭐⭐⭐⭐⭐

I love the elderly, they make it worth wild!

Deborah C.

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⭐⭐⭐⭐⭐

Brittany L.

⭐⭐⭐⭐⭐

I love the elderly, they make it worth wild!

Deborah C.

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⭐⭐⭐⭐⭐

Brittany L.

Contact Information

Chapman Valley Manor Director, Bonny Hicks

Phone: (785) 922-6525

Fax: (785) 922-2186

Email: chapval@chapmanvalleymanor.org

Mailing Address: 1009 Marshall St. P.O. Box 219

Chapman, Kansas 67431-0219

Physical Address: 1009 N Marshall St.

Chapman, Kansas 67431-0219

Business Hours:

Monday: Appointment Only
Tue - Fri: 8:00 am - 4:00 pm
Sat - Sun: Closed

We answer the phone 24/7

Our Location

Browse Our Website

Home
About Us
- Meet Our Staff
Our Facility
Activities
Pre-Admission Forms
Employment Opportunities
Gallery
Reach Out

Contact Information

Chapman Valley Manor Director, Joe Cassidy

Phone: (785) 922-6525

Fax: (785) 922-2186

Email: chapval@chapmanvalleymanor.org

Mailing Address: 1009 Marshall St. P.O. Box 219

Chapman, Kansas 67431-0219

Physical Address: 1009 N Marshall St.

Chapman, Kansas 67431-0219

Business Hours:

Monday: Appointment Only
Tue - Fri: 8:00 am - 4:00 pm
Sat - Sun: Closed

We answer the phone 24/7

Our Location

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