Rush Generations Online Membership Form | Rush | Chicago



Geriatrics



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Geriatric Services

Rush Generations Online Membership Form

Please fill out the following form to become a member of Rush Generations.
(* Required fields)

Contact Information
		First name*	Middle initial
		Last name*
		Address*
		City*
		State*	ZIP*
		Primary phone*
		Date of birth* (MM/DD/YYYY)
		Gender*	M F
		Email

Additional information (please check the response that most accurately describes you)
	Relationship Status*	Divorced Married Separated Single Single living with significant other Widowed
	Do you have advance medical directives?* (power of attorney for health care, living will, etc.)	Yes No
	Do you have grandchildren?*	Yes No
	Race/ethnicity*	African American Asian Caucasian Hispanic/Latino Other
	Primary language*
	Caregiving status*	I am a caregiver I have a caregiver Neither of the above
	Do you have a Rush doctor?*	Yes No

Interests (Please check off up to three in each column)
	Medical interests	Lifestyle interests	Resource interests
	Alzheimer's disease Arthritis Blood pressure Bone health Cancer Cholesterol Depression/mental health Diabetes Eye health Heart health Men's health Pain Respiratory health Stroke Women's health Other None	Arts Collection Computers Crafts Dance Exercise Movies Music Reading Social groups Sports Travel Volunteering Other None	Abuse or neglect Adult day services Advance directives Benefits screening Caregiver support and education Emergency home response Hearing/dental/vision Housing In-home services Medicare/insurance Nursing home services Prescriptions Transportation Other None

How did you hear about us?*

Other:

Contact Name	Rush Generations
Contact Phone	(800) 757-0202
Contact E-mail	contact_rush@rush.edu

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