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Do you need a sign language <br />If yes, notify <br />interpreter? <br />YES / NO <br />Interpreter Strike <br />Team Leader. <br />VISION /SIGHT <br />Circle <br />Actions to be taken <br />Do you wear eyeglasses? Are they <br />YES / NO <br />If no, ask if they <br />with you? <br />need a replacement? <br />Do you have difficulty seeing, even <br />YES / NO <br />If no, skip to the <br />with glasses? <br />next section. <br />Do you use a white cane? Is it with <br />YES / NO <br />If yes, ask next <br />you? <br />questions. <br />If yes, collaborate <br />Do you need help getting around, <br />YES / NO <br />with FNSS Advisor <br />even with your white cane? <br />and Regional <br />Shelter Supervisor. <br />Name of <br />MEDICAL <br />Circle <br />Actions to be taken <br />Individual <br />with Need <br />If yes, refer to <br />Do you have any severe allergies? <br />YES / NO <br />Health <br />Environmental, food, medication? <br />Services/Food <br />Services. List: <br />Do you use special medical equipment <br />or supplies? (Epi -pen, diabetes <br />YES NO <br />/ <br />List: <br />supplies, respirator, oxygen, dialysis, <br />ostomy, etc.) <br />Do you have it with you? <br />YES / NO <br />If no, list potential <br />sources. <br />Have you been in the hospital or <br />under the care of a doctor in the past <br />YES / NO <br />If yes, list reason. <br />month? <br />Do you take any medicine(s) <br />YES / NO <br />regularly? <br />When did you last take your <br />Date /Time <br />medicine? <br />When should you take your next <br />Date /Time <br />dose? <br />If no, identify <br />Do you have the medicine with you? <br />YES / NO <br />medications and <br />process for <br />replacement. <br />Do you have your prescription with <br />YES / NO <br />you? <br />Do you have any other medical needs: <br />YES / NO <br />List: <br />INDEPENDENCE FOR DAILY <br />Circle <br />Actions to be taken <br />Name of <br />LIVING <br />Individual <br />Cabarrus County EOP — Annex L — Shelter and Mass Care <br />Attachment n 12 <br />F -6 Page 301 <br />