Dixie County - Hazardous Material

Current National Threat Level is elevated

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


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