Lake County Department Of Public Safety/emergency Management Division Special Needs Registry Form
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2LAKE COUNTY DEPARTMENT OF PUBLIC SAFETY/EMERGENCY MANAGEMENT DIVISION
Date
Client ID
SPECIAL NEEDS REGISTRY FORM
Florida and Federal law requires that information contained in your medical records be held in strict confidence and not be released without your written consent. The
consent you sign on this page will remain in effect until you request in writing that your consent be withdrawn, which you may do at any time. You have a right to request
and obtain a copy of this consent. This form is intended for Special Needs Registration purposes only. Dissemination, distribution, or copying of this form is strictly
prohibited except for use by authorized persons. The original of this form shall be secured in a locked file.
Home Health Agency
Medical Equipment Supply Co.
Dialysis Center
Other Agency Affiliations (
)
i.e.,
Children's Medical Services; Hearing, Visual, Developmental, Mental Health Services; Other Special Services
PERSONAL INFORMATION
Last Name
First Name
MI
Last 4 of Social Security #
Birthdate (Mo/Day/Yr)
Sex
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__ __ __ __
__ __ /__ __ /__ __ __ __
M
F
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Native Hawaiian/Other Pacific Islander (NH/PI)
Ethnic Group
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African/American (B)
Black & White (B&W)
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Caucasian (W)
American Indian or Alaskan Native & White (AI/AN&W)
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Hispanic (H)
American Indian or Alaskan Native & Black (AI/AN&B)
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Asian or Pacific Islander (AS)
Asian or Pacific Islander and White (AS&W)
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American Indian or Alaskan Native (AI/AN)
2+Races Non-Hispanic (2+NH)
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In City Limit
Yes
No
Street Address
City
Zip
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Mobile Home
Yes
No
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Flood Prone
Mailing Address (if different)
City
Zip
Yes
No
Phone #s (Include Area Code)
Name of Subdivision, MH Park, Apt Bldg., etc.
If address is temporary, give dates:
Home:
_ _ _ - _ _ _ - _ _ _ _
From:
To:
Cell:
_ _ _ - _ _ _ - _ _ _ _
Email Address:
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Living Situation
Lives Alone
With Spouse
With Children
With Parents
Other
_______________________
MEDICAL INFORMATION
(Check and complete those that apply to your medical condition. )
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Required or Life-Sustaining Medical Equipment
Wheelchair Bound
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Oxygen Concentrator
Respirator(Ventilator )
Bedridden
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Portable Oxygen
Suction Machine
Weight > 300 lbs.
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Nebulizer
Other
Hearing Impaired
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Oxygen - Continuous
Amount of Oxygen?
Sight Impaired
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Oxygen - Treatments Only
Speech Impaired
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Amount of Oxygen? _________ How Often? ____________
Memory Impaired
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Oxygen - PRN (As Needed )
Anxiety/Depression
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Nighttime-# of hours?
Emergency Alert Equipment
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Daytime-# of hours?
DNR Order (if checked, attach copy )
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Amount used per day?
Mental Health Impaired (Explain )
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Cardiac History
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Special Dietary Needs (Explain )
Dialysis
How Often?
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Incontinent
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Life-Sustaining Medications (if checked, attach list )
Allergies (List )
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Frail
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Mobility Impaired (Explain ) _____________________________
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heelchair
Walker
Cane
W
Other (Explain )
If disability is temporary, give dates:
Primary Diagnosis:
Secondary Diagnosis:
From:
To:
Emergency Management Use Only
Health Department Use Only
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Previous Application:
Yes
No
SN Cat 1(SN Shelter )
SN Cat 2(Hospital )
SN Cat 3(Registry Only )
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Need More Information
Initials:
If yes, current status:
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