Face Sheet Template
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1FACE SHEET
Name:
DO B:
Sex:
Eye Color:
Hair Color:
Vision:
Hearing:
HT:
WT:
Date Admitted:
Ambulatory: Yes
No
Medi-Cal #:
SSI #:
Current Residence:
Diagno sis:
Special Health Conditions/Problems (include seizure type, frequency, and duration):
Tetanus Date:
Allergies (food, drugs, other):
T.B. Date:
Results:
Prim ary M .D.:
Phone:
Add ress:
Prim ary Dentist:
Phone:
Add ress:
Other:
Phone:
Legal Status: Has consumer been appointed a conservator (for adults) or guardian (for minors): Yes
No
Parent/Guardian/Conservator
Nearest Relative/Emergency Contact
Name:
Name:
Add ress:
Add ress:
City/State/Zip:
City/State/Zip:
Home Phone:
Wo rk Phone:
Home Phone:
Wo rk Phone:
Case W orker:
Agency:
Add ress:
City/State/Zip:
Phone:
Day Program:
Add ress:
City/State/Zip:
Phone:
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Parent category: Medical