Special Needs Registry
Special Needs Registration Form
Hernando County Government
Qualification
The following items help determine if the registrant qualifies for Special Needs.
*
Denotes a required field.
Is registrant dependent upon electricity for the operation of medically necessary equipment?
*
Yes
No
Electricity Dependent Equipment
Apnea Monitor - Detects when a person has prolonged episodes of not breathing
Cardiac Monitor/Life Vest - Battery powered external/wearable defibrillator
CPAP/BiPAP - Machine used during sleep to assist with normalizing breathing
Dialysis catheter (PD) Cycler - Assists with performance of peritoneal dialysis
Feeding Pump - Regulates the flow of liquid nutrition into a feeding tube
IV Pump - Controls flow rate of intravenous medication
Mechanical Ventilator - Machine that supports breathing efforts by strict parameters
Medication that requires Refrigeration - Some insulins, chemotherapy medications
Nebulizer - Provides aerosolized medications to respiratory patients
Oxygen Concentrator - Machine that provides continuous oxygen via nasal cannula
Suction Pump - Provides suction to clear excretions from mouth and nose
Wound Vac - Machine that provides suction to a large/deep wound to promote healing
What is the flow of rate of the Oxygen Concentrator?
*
What is the Oxygen Type?
*
Gaseous
Liquid
Is the registrant dependent upon non-electrical medical equipment?
*
Yes
No
Non-Electricity Dependent Equipment
Dialysis catheter (CVC)
Indwelling Urinary Catheter - Foley or Suprapubic Catheter
Insulin Pump - Implanted or External
Oxygen tanks
PICC line or Midline - Semi-permanent intravenous line for infusion
Port-a-Cath/Infusaport - Implanted infusion device in the chest wall
Tracheostomy - Artificial airway in the throat
Wheelchair - Non-Motorized Wheelchair
Urinary catheter
Gravity Fed Feeding Tube - Non-electric feeding tube that uses gravity to move formula from feeding bag through tube
Are you bringing supplies for dressing changes?
*
Yes
No
Is the registrant dependent upon supplemental oxygen supplied by tank?
*
Yes
No
Does the registrant have any medical or other issues such as impairments or incontinences (If unsure, select Yes)?
*
Yes
No
Medical
Memory
Hearing Impaired - Use of hearing aids or sign language
Visually Impaired - Use of glasses or legally blind
Non-Verbal
Urinary or Bowel Incontinence - Use of adult diapers or pads
Currently enrolled in Hospice Care
Memory
Alzheimers or related dementias
Traumatic brain injury/memory impaired
Non-Verbal
Difficulty understanding verbal instructions
Behavioral
Autism
Bipolar
Combative/Violent
PTSD
Anxiety
Depression
Conduct Disorder
Obsessive Compulsive Disorder
Personality Disorder
Psychosis
Schizophrenia
Self-Injurious or considered a danger to others
Substance Abuse
Dialysis
Peritoneal dialysis
Hemodialysis
Allergies:
Please include any Medications, Environmental Allergies, Seasonal, and Food.
Past medical History
Osteoarthritis/Osteoporosis
COPD
Bedsores
Cancer
Cerebral Palsy
Heart Condition
Diabetes
Kidney Disease
Multiple Sclerosis
Muscula Dystrophy
Ostomy
Seizure Disorder
Stroke
COPD
Asthma
Emphysema
Cystic Fibrosis
Currently receiving cancer treatment?
Yes
No
Heart Conditions
Angina
Congestive Heart Failure
Heart Disease
High Blood Pressure
Pacemaker/AICD
Diabetes
Oral medication Management
Insulin - Refrigeration is Required
Insulin - Refrigeration is not Required
Ostomy
Colostomy
Ileostomy
Urostomy
Stroke
Residual Deficits
Does the registrant have mobility issues (If unsure, select Yes)?
*
Yes
No
Registrant has the following mobility issues (select all that apply)
Registrant is confined to a bed requiring a specialty mattress
Uses a walker
Uses a cane
Needs assistance to walk long distances
Needs assistance to get in or out of a cot
Complete Paralysis
Partial Paralysis
Uses a motorized wheelchair or scooter
Complete Paralysis
*
Hoyer Lift?
Able to tranfer into a wheelchair from bed?
Partial Paralysis:
Does the registrant have transportation needs (If unsure, select Yes)?
*
Yes
No
Registrant has the following transportation needs (select all that apply)
Must be transported in a wheelchair accessible vehicle
Must be transported via stretcher
Weight requires special transportation
Needs continuous oxygen during transport
No medical needs for transport; needs car/bus transport to shelter
Are you the registrant, or are you someone completing the information on behalf of the registrant?
I am the registrant
I am not the registrant
Personal Information
First Name
*
Middle Initial
Last Name
*
Suffix
Select an option
Jr.
Sr.
II
III
IV
V
VI
Date of Birth
*
Gender
*
Select an option
Male
Female
Prefer Not to Answer
Weight (lbs.)
*
Height (ft.)
*
Height (in.)
*
Phone Number
*
Phone Type
*
Mobile
Land Line
Is this Phone TTY/TTD capable?
*
Yes
No
Primary Language
*
Select an option
English
Spanish
Other
Other Language
Email
Physical Address
Street Address Line 1
*
Street Address Line 2
City
*
State
*
Florida
Zip
*
Caregiver and Emergency Contacts
Caregiver's First Name:
Caregiver's Last Name:
Caregiver's Phone Number:
Emergency Contact First Name
*
Emergency Contact Last Name
*
Emergency Contact Phone Number
*
Additional County Information
Is this registrant a client of The ARC of the Nature Coast?
*
Yes
No
Which scenario?
Family member living with an individual with developmental disability as determined by the Florida Agency for Persons with Disabilities.
Individual with developmental disability as determined by the Florida Agency for Persons with Disabilities.
Is The ARC Nature Coast the legal guardian of this registrant?
Yes
No
ARC Guardian First Name:
ARC Guardian Last Name:
ARC Guardian Phone Number:
Address Related Information
Is listed address the same as the mailing address?
*
Yes
No
Mailing Address Line 1
Mailing Address Line 2
City
State
Select an option
Zip
Is the home in a subdivision, complex, or mobile home park?
Please enter the name of the subdivision/complex/park.
Is the home at this address a mobile home?
*
Yes
No
Is the home at this address a high-rise or multi-story home?
Yes
No
Does this home have stairs?
*
Yes
No
Is there a gate that requires a code to enter?
Yes
No
Do you live at this address year-round?
Yes
No
Evacuation Zone
Select an option
A
B
C
D
E
N
Click
here
to search for your Evacuation Zone
Name of Electric Company
*
- Select Electric Company -
WREC
Duke Energy
TECO
Other
Shelter Information
Number of People going to the shelter
*
Number of People who are evacuating and need transportation
Name of the person accompanying you to the shelter
Relationship
Select an option
Caregiver
Family Member
Friend
Service Animal
Do you have animals?
*
Yes
No
Is the animal required because of a disability?
*
Yes
No
Type of Service Animal
*
Select an option
Dog
Miniature Horse
Pets
If your pet is not a service animal, what are your plans for your pet(s)?
*
Boarding
Family/Friends
Vet
Picked up by Animal Services - this option should be chosen as a last resort. Animal Services will pick your pet up before you leave for the shelter and return the pet to you once you are back home.
Are all vaccinations up to date for this animal?
*
Yes
No
Does this animal require medications?
*
Yes
No
Security Code:
*
Submit
Clear
Please use above validation to submit your form.