Emergency Contact Details: Name: __________________________ Relationship: ____________________Phone #: ___________ Name: __________________________ Relationship: ____________________Phone #: ___________ PERSONAL INFORMATIOM Gender: Male Female Height: _______ Weight: ______ Hair Color: _______ Eye Color: ________ □ □ Identifying Marks or Features: ______________________________________________________________ Ethnicity/Race: check all that apply - Answers to these questions will not affect eligibility for services White Asian or Pacific Islander □ □ African American American Indian/Alaskan □ □ Hispanic Other □ □ Religion: SENSORY SKILLS Which best describes the applicant’s Normal Mild/Moderate Severe/Profound loss □ □ □ hearing? Sensitivity to Noise □ Does the applicant use a hearing aid? Yes No □ □ Which best describes the applicant’s Fully sighted Moderate impairment □ □ vision? Severe impairment Blind □ □ Does the applicant use glasses? Yes No □ □ COMMUNICATION Check the responses that best describes the applicants method of communication Verbal Uses signs or communication device □ □ Uses gestures, vocalizations Unable to communicate □ □ AMBULATION Walks Independently Unsteady Gait Walks with Physical Assistance Requires Use of Wheelchair _____ Uses Other Adaptive Equipment to Ambulate (If yes, please describe) ___________________________ ABILITIES AND STRENGTHS Socialization: Indicate accordingly: 1. Never 2. Sometimes 3. Often 4. Always ___ Interacts with others ___ Displays affection appropriately
Emergency Contact Details: Name: __________________________ Relationship: ____________________Phone #: ___________ Name: __________________________ Relationship: ____________________Phone #: ___________ PERSONAL INFORMATIOM Gender: Male □ Female □ Height: _______ Weight: ______ Hair Color: _______ Eye Color: ________ Identifying Marks or Features: ______________________________________________________________ Ethnicity/Race: check all that apply - Answers to these questions will not affect eligibility for services □ White □ Asian or Pacific Islander □ African American □ American Indian/Alaskan □ Hispanic □ Other Religion: SENSORY SKILLS Which best describes the applicant’s hearing? □ Normal □ Mild/Moderate □ Severe/Profound loss □ Sensitivity to Noise Does the applicant use a hearing aid? □ Yes □ No Which best describes the applicant’s vision? □ Fully sighted □ Moderate impairment □ Severe impairment □ Blind Does the applicant use glasses? □ Yes □ No COMMUNICATION Check the responses that best describes the applicants method of communication □ Verbal □ Uses signs or communication device □ Uses gestures, vocalizations □ Unable to communicate AMBULATION Walks Independently Unsteady Gait Walks with Physical Assistance Requires Use of Wheelchair _____ Uses Other Adaptive Equipment to Ambulate (If yes, please describe) ___________________________ ABILITIES AND STRENGTHS Socialization: Indicate accordingly: 1. Never 2. Sometimes 3. Often 4. Always ___ Interacts with others ___ Displays affection appropriately
Universal_app_5-3-12.docx