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Pender County Special Needs Registry Application For Shelter and Evacuation
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Pender County Special Needs Registry Application For Shelter and Evacuation
Last Name
*
First Name
*
Middle Name
*
Patient Phone Number
*
Physical Address
*
City
*
Zip
*
State
*
Mailing Address if Different
Caregiver's Name
*
Caregivers Phone Number
*
Emergency Contact's Name
*
Emergency Contact Phone Number
*
Relationship
*
Emergency Contact Address
*
Your Primary Care Physician
*
Physician's Telephone
*
Home Health Provider
*
Primary Language
*
Do you use oxygen?
*
Yes
No
How Often Do You Use Your Oxygen? (optional)
*
(___ Hours per Day at ___ Rate Liters/Min)
What Type of Oxygen Do You Have? (optional)
Concentrator
Portable Tank
Amount of oxygen you have on hand? (optional)
What Type of Medications Do You Take? (optional)
Oral
Subcutaneous Injections (SQ)
Intramuscular Injections (IM)
Intravenous (IV)
How Mobile Are You? (optional)
Bed Bound
Wheelchair Bound
Walk with Assistance (walker, cane, another person)
Walk Independently
Do You Use Any Special Medical Device? (optional)
Ventilator
Dialysis Machine
Nebulizer
Feeding Pump
CPAP/BIPAP
IV Pump
Suction
Other
Are you... (optional)
Deaf
Blind
Severe Visual Impairment
Severe Hearing Loss
Speech Impairment
Do You Have Any of the Following Devices? (optional)
Urinary Catheter
Ostomy
Pacemaker
Implanted Pump/Catheter/Tube
What Kind of Vehicle Can You Ride In?
Car/Bus
Wheelchair Accessible Vehicle
Ambulance Only
Are You Mentally Handicapped?
*
Yes
No
Do You Have a Service Animal?
*
Yes
No
Please List Any Additional Information You Think Necessary To Your Care Below: (optional)
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