PERSONAL INFORMATION:
Last Name:
First Name:
MI:
Birth Date:
Gender:
Weight:
Height
Street Address:
City:
State:
Zip:
Phone:
Mailing Address(
If different
):
City:
State:
Zip:
Phone:
Name of Subdivision, MH Park, Apt Bldg., etc:
Flood Prone Area:
Yes
No
Temporary Address:
From:
To:
Primary Language Spoken:
Type of Structure(check one)
Mobile
Manufactured
Site Wood Built
Masonry
Other
Living Situation: (check one)
Lives Alone
With Spouse
With Children
With Parents
Other
MEDICAL INFORMATION: (Check and complete those that apply to your medical condition.)
Require Life-Sustaining Medical Equipment ? (Check those that apply)
[You must bring your own equipment with you to the shelter.]
Suction Machine
Respirator (Ventilator)
Positive Airway Pressure Equipment (CPAP)
Nebulizer
Feeding Pump
Other
Oxygen – Type:
Liquid
Gas
Oxygen Concentrator
Continuous
As Needed
Occasional
How Often
Rate
(liters/min)
Amount used per day?
How is it given?
Check any of the following that apply to you
Seizures (Explain)
Colostomy or Ileostomy
Stroke
Cardiac History
Dialysis
How Often?
Urine Control Problem
Bowel Control Problem
both
Memory Impaired
(Explain)
Psychiatric/Personality Disorder
Anxiety/Depression
Alzheimers
Dementia
Autism
Obsessive Compulsive Disorder
Conduct Disorder
Mental Health Impaired
(Explain)
Frail
Mobility Impaired
(Explain)
.
Require equipment to help with mobility?
Wheelchair Bound
Walker
Other
Bedridden
Bedridden
Can you transfer to a wheel chair
Sensory Impaired
Hearing
Sight
Speech
Other
Equipment used to assist with impairment
Other
DNR Order (if so, attach copy )
Special Dietary Needs
(Explain )
Medication
Medication requiring refrigeration
Assistance required with Medications
List of all medications:
Allergies (List)
List of all other medical conditions:
EMERGENCY CONTACT INFORMATION: 1 Local and 1 Non-Local
(Local) First Name
Last Name
Relationship
Phone
(Non-Local) First Name
Last Name
Relationship
Phone
PHYSICIAN/PHARMACY INFORMATION:
Physician's Last Name:
First Name:
Phone:
Pharmacy Name:
Phone:
Home Health Care Agency Name:
Phone:
Hospice:
Phone:
Dialysis Center:
Phone:
Medical Equipment Provider:
Phone:
SHELTER INFORMATION:
PET INFORMATION:
Plan on using a shelter?
Yes
No
Provide Own Transportation to Shelter:
Yes
No
If you need assistance with transportation, check one of the following:
automobile
van with wheelchair lift
stretcher
Trained Service Animal
(Only service animals are allowed in the shelters.)
(Make arrangements for your pet with a vet, kennel, or bring your pet to our pet friendly shelter.)
Name of person going with patient to the shelter:
Relationship to patient:
Phone:
AUTHORIZATION INFORMATION:
I agree that my name be added to the Special Needs Emergency Shelter list. I give Levy County Emergency Management
authorization to share this information with other local support agencies in the event of an emergency evacuation. I also grant emergency response personnel permission to enter my home during search and rescue operations following a disaster, if necessary, to assure my safety and welfare.
Patient Signature: ________________________________________________________________ Date: ___________________
Authorized Signature: ____________________________________________________________ Date: ___________________
Relationship to Patient: ___________________________________________________________ Date: ___________________
Mail Form to: Levy County Emergency Management, PO Box 221, Bronson, FL 32321 (352) 486-5213
EMERGENCY MANAGEMENT USE ONLY:
Previous Application:
Yes
No
SN
Public Shelter
Stay Home
Dialysis Center
Need More Information
Approved:
Denied:
Reason:
Initials:
9/10/08