emasmall MARSHALL COUNTY EMERGENCY MANAGEMENT AGENCY emasmall
DATE SPECIAL NEEDS REGISTRATION FORM CLIENT ID
Alabama and federal law requires that information contained in your medical records be held in strict confidence and not be released without your written consent.
The consent you sign on this form will remain in effect until you request in writting that your consent be withdrawn, which you may do at any time. You have a right to request and obtain a copy of this consent. This form is intended for Special Needs Registration Purposes only. Dissemination, distribution, or copying of this form is strictly prohibited except by use by authorized persons. The original of this form shall be secured in a locked file.
Client's Last Name First Middle
Street
Address
City State Zip Do you live in the City Limits? YES
Home Phone Cell Phone 1 Cell Phone 2
Email
Address
TTY
NAME OF SUBDIVISION or MOBILE HOME PARK or APARTMENT BUILDING or ASSISTED LIVING FACILITY, ETC.,
LIVING SITUATION Lives Alone With Spouse With Children With Parents Other
EMERGENCY CONTACT INFORMATION
NAME RELATIONSHIP
ADDRESS CITY STATE ZIP
WORK PHONE HOME PHONE CELL PHONE
MEDICAL INFORMATION (Check and complete those that apply to your medical condition.)
Required or Life-Sustaining Medical Equipment
Oxygen Concentrator Respirator
Portable Oxygen Suction Machine
Nebulizer Other
Oxygen - Continuous    Amount of Oxygen?
Oxygen - Treatments Only
   Amount of Oxygen? How Often?
CPAP Machine Asthma
Dialysis How Often?
Name of Dialysis Center:
Location of Dialysis Center:
Cardiac History Pace Maker
Hypertension/Stroke
Diabetes Insulin Dependent
Incontinent Frail
Mobility Impaired (Explain)
Wheelchair Motorized ChairWalkerCrutchesCane
Requires Lifting Assistance
Refrigeration Required for Medicines
life Sustaining Medications (if Checked, Provide attachment)

Do you have backup Power? Yes No
Do you have backup Oxygen Tanks? Yes No Size:
Wheel Chair Bound Colostomy or Ileostomy
Bedridden Indwelling Catheter
Weight > 300 lbs
Hearing Impaired Hearing Aids Deaf
Sight Impaired Legally Blind
Speech Impaired
Memory Impaired Alzheimer's Dementia
Anxiety/Depression
Emergency Alert Equipment
Service Animal
DNR Order (If Checked, attach copy)
Mental Health Impaired (Explain)
Special Dietary Needs (Explain)
Allergies (List)
Monitors (List)
Other:
PHYSCIAN/PHARMACY INFORMATION (Check and complete those that apply to your medical condition.)
Physcian's Last Name First Name Phone
Pharmacy Name City Phone
HOME HEALTH AGENCY NAME Phone
Oxygen & Med Supply Company Phone
Emergency Management
Use Only:
Date Received: Date Entered: GIS Mapping Date: