SPECIAL MEDICAL NEEDS PROGRAM
LEE COUNTY EMERGENCY MANAGEMENT
PO Box 398, Fort Myers, FL 33902-0398
For information call: 239-533-0640
Fax: 239-477-3636
Email: EMspecialneeds@leegov.com
Applications will NOT be processed when Lee County is in the 5-day hurricane forecast cone.
Personal Information
First Name
*
MI
Last Name
*
Suffix
Date of Birth
*
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1911
Gender
M
F
Height (Ft)
Height (In)
Weight
Primary Language
English
Spanish
Creole
Other
Other Language
*
Veteran
No
Yes
Primary Phone
*
TTY Device
No
Yes
Secondary Phone
Email
Preferred Contact Method
Select...
Phone
Email
Text
Physical Address
Address
Apt/Unit
City
State
Zip Code
Subdivision/Community
Gate Code
Stairs
No
Yes
Number of flights
Residence Type
Select...
Single Detached Home
Duplex
Apartment/Condominium
Mobile/Manufactured Home
Boat
Living Situation
Select...
I live alone
I live with relatives
I live with a caregiver
Other
Living with a Spouse
No
Yes
Utility Company
Mailing Address
Same as above
Address
Apt/Unit
PO Box
City
State
Zip Code
Caregiver Information
Do you require a 24-hour caregiver?
No
Yes
Will your caregiver travel and stay with you at the shelter?
No
Yes
First Name
Last Name
Primary Phone
Secondary Phone
Email
Primary Emergency Contact - Local Preferred
First Name
Last Name
Contact is local
No
Yes
Relationship
Address
Apt/Unit
City
State
Zip Code
Primary Phone
Secondary Phone
Email
Secondary Emergency Contact - Out of Area Preferred
First Name
Last Name
Contact is local
No
Yes
Relationship
Address
Apt/Unit
City
State
Zip Code
Primary Phone
Secondary Phone
Email
Provider Information
Doctor
Primary Care Physician
Primary Care Phone
Home Health
HHA Provider
HHA Contact Name
HHA Phone
I have a Do Not Resuscitate (DNR). Your original document, signed by your doctor, MUST be with you at the shelter.
No
Yes
Oxygen Assessment
Oxygen Type
*
Select...
24 Hours
Overnight
Other
Liters Flow (L/min)
*
If other please specify
Oxygen Company
Oxygen Company Phone
Special Care Assessment
Blind/Low Vision
Seizures
Feeding Tube
Insulin Dependent
IM or IV Injections
Deaf/Hard of Hearing
Chronic Wounds
Decubitus Ulcers
Frail/Elderly
CDiff
MRSA
Recent Hospital Discharge
Terminally Ill
Hemodialysis (At Home)
Hemodialysis (Facility)
Hemodialysis Frequency
Dialysis Facility Name
Dialysis Facility Phone
Other Special Care
Cognitive Assessment
- please provide stage level of Mild/Early, Moderate, or Late/Advanced for all Cognitive conditions
Dementia
Bipolar Disorder
Obesessive Compulsive Disorder
Anxiety
Developmental Impairment
Causes harm to self/others
Alzheimer's Disease
Depression
Psychiatric Disorder
Conduct Disorder
Parkinson's
Autism Spectrum
Autism Level
High Functioning
Moderate
Low Functioning
Nonverbal
Other Cognitive Issues
Mobility Assessment
I can walk on my own
I need an attendant to help with walking
I can stand and walk with a cane
I use a walker/wheeled seat walker
I am bed-bound
I use a standard wheelchair
I use a motorized wheelchair/scooter
I require stretcher transport
I weigh over 300 lbs
I need a Hoyer lift
Amputee
Paraplegic
Quadriplegic
White Cane
I have a Serivce Animal
Multiple Sclerosis (MS)
Muscular Dystrophy (MD)
ALS (Lou Gehrig’s Disease)
Other Mobility Issues
What help do you require?
Walking
Standing
Getting in/out of bed
Communicating
Bathing/Showering
Dressing
Toileting
Feeding
Wound care
Ostomy
External or Self Catheter
Bowel/Bladder Incontinence
Assistance w/ Medications
Other Help Requirements
Electricity Assessment
Ventilator
Nebulizer
Feeding Pump
Oxygen Concentrator
Cardiac Monitor
Refrigerated Medication
Apnea Monitor
Other Electrical Dependencies
Additional Medical Information
I have allergies
Other Medical Info
Transportation to Shelter
I will provide my own transportation
I need transportation - Paratransit Bus
I am bed-bound and require stretcher
Pet Sheltering Needs
Service Animal
Comfort Animal
Name
Type
Breed
Weight
Carrier/Cage
Leash
Muzzle
Add Pet or Service Animal
Registrant Info
Representative’s Name
*
Representative’s Contact Information
*
Representative’s relationship to Registrant
*
Self
Spouse/Partner
Neighbor/Friend
Case Worker
Home Health Care Aide
Other
Other
*
I understand this registration is voluntary and do hereby request to be registered in the Lee County Special Medical Needs Program. The information contained herein is true and correct to the best of my knowledge. I understand there are limitations to the services and levels of care that are available. I hereby grant permission to medical providers, transportation agencies, and others, to provide care and respond to my needs, and for the disclosure of any information necessary to do so. I also grant permission to emergency response agencies to enter my residence for the purpose of emergency search and rescue, and authorize the release of information necessary for these agencies to perform these services. In an effort to ensure the safety of all shelter residents, a background screen will be run on all people evacuating to the Special Medical Needs Shelter, including the caregiver.
Submit
Add Pet or Service Animal
×
Service Animal
No
Yes
Comfort Animal
No
Yes
Animal Name
Type of Animal
(required)
Breed
Weight (lbs)
Has Carrier
No
Yes
Has Leash
No
Yes
Has Muzzle
No
Yes
