Laserfiche WebLink
Do you use medicine, equipment, or <br />electricity to operate medical <br />YES / NO <br />If yes, refer to <br />equipment or other items for daily <br />Heath Services. <br />living? <br />Do you normally use a caregiver, <br />If yes, ask next <br />personal assistant, or service animal? <br />YES / NO <br />question. If no, skip <br />next question. <br />If no circle which <br />Is your caregiver, personal assistant, <br />one and refer to <br />or service animal here or can they <br />YES / NO <br />Health Services/ <br />come? <br />DART. <br />If yes, list their <br />name. <br />Do you need help getting dressed, <br />YES / NO <br />If yes, specify and <br />bathing, eating, and/or toileting? <br />explain. <br />Do you need help with your <br />YES / NO <br />If yes, specify and <br />medications? <br />explain. <br />Do you need help moving around or <br />YES / NO <br />If yes, explain. <br />getting in and out of bed? <br />If no, consult <br />Do you have a family member, friend, <br />Shelter Manager to <br />or caregiver with you to help with <br />YES / NO <br />determine if general <br />these activities? <br />population shelter is <br />appropriate. <br />Do you rely on a mobility device such <br />If skip the next <br />as a cane, walker, wheelchair or <br />YES / NO <br />question. on. If yes, list. <br />transfer board? <br />Do you have the mobility <br />If no, identify <br />device /equipment with you? <br />YES / NO <br />potential resources <br />for replacement. <br />If needed, identify <br />Do you wear dentures? Do you have <br />YES / NO <br />potential <br />them with you? <br />resources for <br />replacement. <br />If yes, list special <br />Are you on any special diet? <br />YES / NO <br />diet and notify <br />feeding staff. <br />If yes, list food <br />Do you have food allergies? <br />YES / NO <br />allergies and notify <br />feeding staff. <br />SUPERVISION AND SUPPORT <br />CIRCLE <br />ACTIONS <br />Name of <br />Individual <br />Do you or any of your family <br />If yes, list type and <br />members require additional support <br />YES / NO <br />frequency. <br />or supervision? <br />Cabarrus County EOP — Annex L — Shelter and Mass Care <br />Attachment number 12 <br />F -6 Page 302 <br />