First Name 

Last Name:

Male     Female    Age:

Street#    Apt:

Street Name

City

State

Zip

Phone Number

LIVING SITUATION

Alone   Care Giver

W/Spouse    Other (List)

Blind or sight impaired:     Respirator Dependent       Foley catheter                

Deaf or hearing impaired:  Used Oxygen Daily:          Contagious illness:          

Memory impaired:             Tracheotomy                   Mentally Health impaired

Primary Language  (Eng)   Diabetic                            Disaster Classification

Confined to bed                  Insulin Dependent     

Confined to wheelchair      On dialysis                 

Cardiac Problems               Intravenous line         

Respiratory Problems         Feeding tube               

Name type of oxygen equipment or machine

Other emergency equipment

Other physical or mental conditions

Allergies

Do you have transportation to be able to evacuate     YesNo 

Can you get yourself to a shelter                                YesNo 

Do you have a plan for shelter in case of evacuation  YesNo 

Is your Companion/Caregiver/Spouse going with you  YesNo 

Primary mode of transportation by car                      YesNo 

Primary mode of transportation by wheel-chair van   YesNo 

Primary mode of transportation by ambulance           YesNo 

Name of Ambulance Company frequently used  

Ambulance Phone Number                                 

Person completing Database Form                    

Person completing Form Phone Number           

Person completing Form Email                        

Date Form completed                                       

Next of Kin Name  

Phone Number        

IMPORTANT NAMES AND NUMBERS:

Primary Physician's Name              

Primary Physician Phone Number  

Hospital Preference                        

Home Health/Hospice Agency Name

Home Health/Hospice Phone Number