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AG 2014 04 21
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AG 2014 04 21
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Last modified
4/22/2014 1:43:44 PM
Creation date
11/27/2017 10:43:28 AM
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Meeting Minutes
Doc Type
Agenda
Meeting Minutes - Date
4/21/2014
Board
Board of Commissioners
Meeting Type
Regular
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Environmental, food, medication? <br />Services /Food Services. List: <br />Do you use special medical equipment or supplies? <br />(Epi -pen, diabetes supplies, respirator, oxygen, <br />YES / NO <br />List <br />dialysis, ostomy, etc.) <br />Do you have it with you? <br />YES / NO <br />If no, list potential sources <br />Have you been in the hospital or under the care of a <br />YES / NO <br />If yes, list reason. <br />doctor in the past month? <br />Do you take any medicine(s) regularly? <br />YES / NO <br />When did you last take your medicine? <br />Date/Time. <br />When should you take your next dose? <br />Date/Time. <br />If no, identify medications and <br />Do you have the medicine with you? <br />YES / NO <br />process for replacement. <br />Do you have your prescription with you? <br />YES / NO <br />Do you have any other medical needs: <br />YES / NO <br />List <br />INDEPENDENCE FOR DAILY LIVING <br />Circle <br />Actions to be taken <br />Name of Individual <br />Do you use medicine, equipment, or electricity to <br />operate medical equipment or other items for daily <br />YES / NO <br />If yes, refer to Heath Services. <br />living? <br />Do you normally use a caregiver, personal assistant, or <br />If yes, ask next question. If no, <br />service animal? <br />YES NO <br />/ <br />skip next question. <br />If no circle which one and refer to <br />Is your caregiver, personal assistant, or service animal <br />YES / NO <br />Health Services! DART. <br />here or can they come? <br />If yes, list their name. <br />Do you need help getting dressed, bathing, eating, <br />YES / NO <br />If yes, specify and explain. <br />and /or toileting? <br />Do you need help with your medications? <br />YES / NO <br />If yes, specify and explain. <br />Do you need help moving around or getting in and <br />YES / NO <br />If yes, explain. <br />out of bed? <br />If no, consult Shelter Manager to <br />Do you have a family member, friend, or <br />YES / NO <br />determine if general population <br />caregiver with you to help with these activities? <br />shelter is appropriate. <br />Do you rely on a mobility device such as a cane, <br />If no, skip the next question. If <br />walker, wheelchair or transfer board? <br />/ <br />YES NO <br />yes, list. <br />Do you have the mobility device /equipment with <br />If no, identify potential resources <br />you? <br />YES / NO <br />for replacement. <br />Do you wear dentures? Do you have them with <br />If needed, identify potential <br />you? <br />YES NO <br />/ <br />resources for replacement. <br />If yes, list special diet and notify <br />Are you on any special diet? <br />YES / NO <br />feeding staff. <br />If yes, list food allergies and notify <br />Do you have food allergies? <br />YES / NO <br />feeding staff. <br />SUPERVISION AND SUPPORT <br />CIRCLE <br />ACTIONS <br />Name of Individual <br />Do you or any of your family members require <br />YES / NO <br />If yes, list type and frequency. <br />additional support or supervision? <br />Are you presently receiving any benefits <br />If yes, list type and benefit <br />(Medicare /Medicaid) or do you have other health <br />YES / NO <br />number(s) if available. Make <br />insurance coverage? <br />photocopy of card. <br />Do you need access to a 12 -step program? Which <br />YES / NO <br />List program type. <br />one? <br />Would you like to register on the Red Cross SAFE <br />YES / NO <br />If yes, provide registration form. <br />Cabarrus County EOP — Annex L — Shelter and Mass Care <br />Attachmentnnumber 12 <br />F -6 Page 289 <br />
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