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Lakeside Nursing and Rehabilitation Center
1229 Trumansburg Road, Ithaca, New York 14850
607-273-8072

SOCIAL HISTORY
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Resident's Name
First
Middle
Last
Maiden
Email
Residential or Home Address
City
State
Zip
Birth Date
Place of Birth
National Origin
Primary Language
Mother's Name
First
Middle
Last
Maiden
Father's Name
First
Middle
Last
Marital Status	Single Married Widowed Separated Divorced Partnered
Significant Other's Name
First
Middle
Last
Relationship
Maiden
Date of Marriage
If deceased, Date of Death
Cause of Death
Occupation
Children(Please list oldest to youngest)
First
Middle
Last
Age
If deceased, cause of death
First
Middle
Last
Age
If deceased, cause of death
First
Middle
Last
Age
If deceased, cause of death
First
Middle
Last
Age
If deceased, cause of death
Siblings(Please list oldest to youngest)
First
Middle
Last
Age
If deceased, cause of death
First
Middle
Last
Age
If deceased, cause of death
First
Middle
Last
Age
If deceased, cause of death
First
Middle
Last
Age
If deceased, cause of death
Resident's Education
Grade School
City
State
Last Grade Completed
High School
City
State
Last Grade Completed
College
City
State
Last Grade Completed
Trade School
City
State
Last Grade Completed
Employment	Occupation(s) Date(s) Retired(Y/N)
Armed Services
Are you or your spouse a veteran?	Yes No
If so, what branch?
Dates of Service	to
During which war/conflict?
Service related occupation
Living Arrangements Prior to Nursing Home Placement
Select Applicable	Own Home Apartment With Family Other
Where have you lived?
City
State
Country
Date
City
State
Country
Date
City
State
Country
Date
City
State
Country
Date
City
State
Country
Date
Recreational and Leisure Time Interests
Hobbies
Crafts
Music
Clubs
Community Service
Travel
Other Interests
Spiritual/Religious Affiliations
Religion
Church
Significant Lifetime Achievements/Events/Contributions
Additional Information
Attestation: According to the best of my knowledge and belief, the above information is accurate and true in all respects.
Signature of Person Completing History By writing your name you hereby agree to the above Attestation
Date
Signature of Social Worker By writing your name you hereby agree to the above Attestation
Date