Personal Information
First Name:
Middle Init:
Last Name:
Social Security Number:
Date of Birth:
Mailing Address:
City:
State:
Zip:
(check if Physical Address same as Mailing Address)
Physical Address:
City:
State:
Zip:
Phone Number:
Live Alone:
Yes
/ No
Mobile Home:
Yes
/ No
Emergency Contact:
Phone:
Relationship:
Doctor:
Phone:
Special Care Requirements
Please Check The Type of Assistance
You Require:(check only one)
Special Care Shelter Assignment Only
(no transportation required)
Transportation to Public Shelter
Transportation to Special Care Shelter
Transportation to Nursing Home/Hospital
Medical Condition
Medical/Physical Condition:
Blind:
Yes
/ No
Seeing Eye Dog:
Yes
/ No
Cane:
Yes
/ No
Legally Blind:
Yes
/ No
Hearing Impaired :
Yes
/ No
If yes, TDD Number:
Vision Impaired:
Yes
/ No
Glasses:
Yes
/ No
Medical Assist Dog :
Yes
/ No
Special Equipment
Dialysis Patient:
Yes
/ No
Treatments per Week:
1
/2
/3
At Home :Yes
/No
Medication
Food or Drug Allergies?
Yes
/ No
If yes, Please State:
Oxygen Required?
Yes
/ No
Oxygen Valve Set On:
1
/ 2
/ 3
/ 4
Electrical Need
Continuous
Intermittent
None
Mobility
Amulatory:
Can You Feed Yourself: Yes
/No
Ambulatory Assistance:
Crutches
/Cane
/ Walker
Wheelchair:
Own Wheelchair: Yes
/No
Bedridden:
Can Go to RestRoom Alone: Yes
/No
If Bedridden Can You
Be Evacuated In:
Stretcher
/ Wheelchair
Treatment Given By Home Health Agency:
Aditional Information:
Special Diet:
People to Accompany:
Phone:
Comments/Directions:
Do You Own A DNR
(Do Not Resucitate)?
Yes
/ No
If yes, Bring With You To Shelter
Completed By:
Alert Warning
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