Fillable 508 LIS 026 050520 IDD Health Profile D Af

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508 LIS 026 050520 IDD Health Profile D Af

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Health Profile
I have a disability. Please read this so
you can best assist me.
Full name
What I like to be called Date of birth
Something important to know about me (examples: include your strengths, something you
like about yourself or something you are proud of):
Important people to talk to about my health
My doctor
Phone number
Other important people to talk to about my health
(examples: medical providers, aides, family or friends):
Relationship Phone number
Name
Relationship Phone number
Emergency contacts
Name
Relationship Phone number
Name
Relationship Phone number
My photo
I communicate by
Check all that apply
Writing or typing
Talking
Sign language
Pointing to words
Pictures
Using a device
Gestures/body language
Other
I understand these spoken language(s):
C
A
L
I
F
O
R
N
I
A
L
I
S
T
O
S
Health Profile
Information about my health
(examples: medical issues such as diabetes, seizures, cancer, heart condition)
(today’s date)
Medications I take now
Medication name
Dosage and frequency How I take it Why I take it
Medication name
Dosage and frequency How I take it Why I take it
Medication name Dosage and frequency How I take it Why I take it
Medication name
Dosage and frequency How I take it Why I take it
Medication name
Dosage and frequency How I take it Why I take it
Medication name
Dosage and frequency How I take it Why I take it
Medication name Dosage and frequency How I take it Why I take it
Medication name
Dosage and frequency How I take it Why I take it
Medication name
Dosage and frequency How I take it Why I take it
C
A
L
I
F
O
R
N
I
A
L
I
S
T
O
S
Health Profile
I am allergic to
Medication or food
My symptoms or reactions (list significant reactions)
Medication or food
My symptoms or reactions (list significant reactions)
I have dietary restrictions
My food restrictions and reasons are: (examples: diabetes, intolerances, textures, smells)
Food Reason
Food Reason
Food Reason
Self-expression
I might get upset from: (examples: noises, lighting, being touched, smells, face masks)
When I am anxious or stressed, I feel better when:
When I am hurt or sick, I feel better when:
When I am in pain, I show it by:
I need help with
Check all that apply
Eating
Drinking
Washing
Bathroom
Dressing
Other
Other
My devices and aids
Check all that apply
Glasses
Reading device/aid
Writing device/aid
Wheelchair
Service animal
Hearing aids
Walker/cane
Other
Other
Other
C
A
L
I
F
O
R
N
I
A
L
I
S
T
O
S
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508 LIS 026 050520 IDD Health Profile D Af

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Completed 18 July 2020

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