Tab K- Medical/Functional Needs Discharge Assessment Name of Shelter Guest: DOB / Age: Gender: Male / Female Residence Address (street, county, state): Current Location: Current Location: Name, Address (include county, city and state) & Phone Shelter Nursing Home Hospital Hotel Other: Do you have any chronic/acute If yes, describe health care condition: health care conditions? Yes No Were you receiving any of the following services/support in your home prior to evacuation or will you need any of the following when you return? Care/Item Services Needed Name and location of pre-hurricane services Home Health Hospice Care Durable Medical Equipment Physical Therapy Oxygen Dialysis Psychiatric/Psychological Other Local Jurisdiction Ready For Return? TYPE OF TRANSPORTATION NEEDED: Is wheelchair: Yes Wheelchair accessible Powered No Ambulance Oversized Bariatric capable Ambulance Manual Bus Able to fold up: Yes No Other Needs immediate follow up for Needs immediate case management? Flu shot given? medical care? Yes No Yes No Yes No Destination availability confirmed? Do you need assistance to get to destination? Yes Yes No UNKNOWN No Return Location: Address (include county, city & Contact Name and Phone: Home state): Assisted Living Other Need Shelter Do you use oxygen? Yes No AMOUNT (flow) _____ Do you have enough oxygen to return home? Yes No Do you have a pet in shelter? Yes No Type Pet Name Have arrangements been made to reunite with pet? Yes No COMMENTS: Name of Assessor/Data Collector: Date of Assessment:
Tab K- Medical/Functional Needs Discharge Assessment Name of Shelter Guest: Residence Address (street, county, state): DOB / Age: Gender: Male / Female Current Location: Shelter Nursing Home Hospital Hotel Other: Current Location: Name, Address (include county, city and state) & Phone Do you have any chronic/acute health care conditions? Yes No If yes, describe health care condition: Were you receiving any of the following services/support in your home prior to evacuation or will you need any of the following when you return? Care/Item Services Needed Name and location of pre-hurricane services Home Health Hospice Care Durable Medical Equipment Physical Therapy Oxygen Dialysis Psychiatric/Psychological Other Local Jurisdiction Ready For Return? Yes No TYPE OF TRANSPORTATION NEEDED: Wheelchair accessible Ambulance Bariatric capable Ambulance Bus Other Is wheelchair: Powered Oversized Manual Able to fold up: Yes No Needs immediate follow up for medical care? Yes No Needs immediate case management? Yes No Flu shot given? Yes No Destination availability confirmed? Yes No UNKNOWN Do you need assistance to get to destination? Yes No Return Location: Home Assisted Living Other Need Shelter Address (include county, city & state): Contact Name and Phone: Do you use oxygen? Yes No AMOUNT (flow) _____ Do you have enough oxygen to return home? Yes No Do you have a pet in shelter? Yes No Type Pet Name Have arrangements been made to reunite with pet? Yes No COMMENTS: Name of Assessor/Data Collector: Date of Assessment:
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