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Environmental, food, medication? Services /Food Services. List: Do you use special medical equipment or supplies? (Epi -pen, diabetes supplies, respirator, oxygen, YES / NO List dialysis, ostomy, etc.) Do you have it with you? YES / NO If no, list potential sources Have you been in the hospital or under the care of a YES / NO If yes, list reason. doctor in the past month? Do you take any medicine(s) regularly? YES / NO When did you last take your medicine? Date/Time. When should you take your next dose? Date/Time. If no, identify medications and Do you have the medicine with you? YES / NO process for replacement. Do you have your prescription with you? YES / NO Do you have any other medical needs: YES / NO List INDEPENDENCE FOR DAILY LIVING Circle Actions to be taken Name of Individual Do you use medicine, equipment, or electricity to operate medical equipment or other items for daily YES / NO If yes, refer to Heath Services. living? Do you normally use a caregiver, personal assistant, or If yes, ask next question. If no, service animal? YES NO / skip next question. If no circle which one and refer to Is your caregiver, personal assistant, or service animal YES / NO Health Services! DART. here or can they come? If yes, list their name. Do you need help getting dressed, bathing, eating, YES / NO If yes, specify and explain. and /or toileting? Do you need help with your medications? YES / NO If yes, specify and explain. Do you need help moving around or getting in and YES / NO If yes, explain. out of bed? If no, consult Shelter Manager to Do you have a family member, friend, or YES / NO determine if general population caregiver with you to help with these activities? shelter is appropriate. Do you rely on a mobility device such as a cane, If no, skip the next question. If walker, wheelchair or transfer board? / YES NO yes, list. Do you have the mobility device /equipment with If no, identify potential resources you? YES / NO for replacement. Do you wear dentures? Do you have them with If needed, identify potential you? YES NO / resources for replacement. If yes, list special diet and notify Are you on any special diet? YES / NO feeding staff. If yes, list food allergies and notify Do you have food allergies? YES / NO feeding staff. SUPERVISION AND SUPPORT CIRCLE ACTIONS Name of Individual Do you or any of your family members require YES / NO If yes, list type and frequency. additional support or supervision? Are you presently receiving any benefits If yes, list type and benefit (Medicare /Medicaid) or do you have other health YES / NO number(s) if available. Make insurance coverage? photocopy of card. Do you need access to a 12 -step program? Which YES / NO List program type. one? Would you like to register on the Red Cross SAFE YES / NO If yes, provide registration form. Cabarrus County EOP — Annex L — Shelter and Mass Care Attachmentnnumber 12 F -6 Page 289