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Medical Condition(s)
Additional Comments
Briefly, please describe any additional medical comments
Medications
Please list any medications taken
Consequences Without
Please describe the consequences without these medications
Physical Handicaps
Please list and briefly describe any physical handicaps
Psychological Problems
Please list and briefly describe any psychological problems
Attending Physician's Name
Physician's Phone Number
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Last Name*
First Name*
Date of Birth*
Relationship to Patient*
Address*
City*
State*
Zip Code*
Phone Number*
Email Address*
Residence Notes
Does the patient live with the caregiver?*
1. Yes
2. No
Is the caregiver present in the home 24 hours each day?*
1. Yes
2. No
Who else is present?
If the caregiver is not present 24 hours each day, please describe who else is present, such as: secondary caregiver or the time gap when the primary is not present.
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Tobacco product use?*
1. Yes
2. No
Type:
Brand:
Matches:*
1. Yes
2. No
Lighter:*
1. Yes
2. No
Type of lighter:
Food items desired:*
Candy or gum desired:*
Tissue, handkerchief or other pocket/purse items? *
Approximate amount of cash normally kept on them? *
Where is the cash on their person?
Please describe common jewelry worn:*
Describe their wallet, purse, or backpack. *
Please describe any other items the patient/client likes to carry? (Ex.: cane/walking stick, particular toys, comfort item).*
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Is the patient/client familiar with their surrounding area? *
1. Yes
2. No
If not local, what other areas are known to the client? *
Please describe any outdoor/survivalist/first-aid training classes the patient/client has taken.*
Please list Military Experience:*
Branch, location(s), years
Please describe any overnight camping/scouting experience. *
Does the patient/client ever go out alone?*
1. Yes
2. No
Has the patient/client ever been lost before? If yes, describe when and where they were found (this can help us establish a pattern so be as specific as possible).*
Was the patient/client located by searchers or walked out by themselves?
Was 911 contacted? If so, which county?
If out, will they stay on trails/sidewalks or wander? *
Please describe general athletic interests/abilities.*
Can the patient/client swim? *
1. Yes
2. No
3. Unknown
Are there any bodies of water/pools near the clients residence?*
1. Yes
2. No
Please describe locations and descriptions of pools or bodies of water.
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