Hillsborough County Health Department Shelter Evaluation Form
(PLEASE PRINT)
Last Name:
First Name:
Middle
Initial:
Last 4 digit of SS:
XXX-XX-
Sex:
Male Female
Height:
Weight:
Date of Birth:
Telephone:
Primary Language:
Street Address:
Lot/Apt #
City:
Zip Code:
Living Arrangements: Alone With Relative Other:
Mailing Address(if different):
City:
Zip Code:
Mobile Home?: Yes No
Mobile Home Park Name:
Local Emergency Contact Name:
Relationship:
Telephone:
Out of Town Emergency Contact Name
Relationship:
Telephone:
Caregiver Name:
Relationship:
Telephone:
Only immediate family living in household can accompany you to the shelter.
Primary Doctor’s Name:
Telephone
Home Health Agency:
Telephone
Name Your Medical Problems: (Bring List of Medications with you to the Shelter)
Are you under the care of HOSPICE? Yes No (HOSPICE patients do NOT need to complete this form.
They should contact their HOSPICE caregiver to arrange for special needs shelter and/or transportation.)
TRANSPORTATION: Do you need a ride to the Shelter? Yes No
Mobility Assessment: (Check all that apply) Electric Dependent (Check all that apply)
I can walk Wheelchair/scooter
Walker Cane
Bedridden Uses lift to get out of bed
Hearing Impaired Deaf
Blind Partially Blind
Cognitive Assessment: (Check all that apply)
Feeding Pump Suction Pump
Nebulizer Cardiac Monitor
Apnea Monitor CPAP/BPAP
Ventilator Concentrator
Oxygen No. of hrs. daily
Liter Flow Portable Tank
Dialysis
Other
Special Care: (Check all that apply)
Mental Health Problems Psychiatric
Alzheimer’s
Autism
Conduct Disorder
Obsessive Compulsive
Anxiety
Depression
Dementia
Open Wound Ostomy
Catheter Incontinence/Adult Diapers
Assistance required with medication?
I need a nurse or caregiver to administer
medication
I have Trained Service Animal:
What kind?
What arrangements have you made for your pets?
By signing this form I give my authorization for the medical information contained herein to be released to the county health
department, emergency management, local fire districts, and receiving facilities for the purpose of evaluating my needs and
providing emergency transportation and sheltering. Records relating to registration of disabled citizens are exempt for the
provisions of F.S. 119.07(1), Public Records Law. The information contained here will be kept confidential.
_________________________________________________ _________________
Signature of Patient / Guardian Date Signed
Return form to: Hillsborough County Health Department PO Box 5135 Tampa, Fl 33675-5135
Or FAX to (813) 276-8689. For more information call (813) 307-8063
For Office Use Only (Check all that apply):
Special Needs Shelter: __________ Red Cross Shelter: __________ Hospital: _________ Shriners: __________ Dialysis: __________ FAHA__________ Aging Services__________
T
Failure to com
lete the entire form WILL dela
our evaluation!
