Patient Emergency Preparedness Plan Form
Identifying Information
Patient Name
SOC Date
/
Month
/
Day
Year
Date
Patient Address
City
State
Zip
Patient Phone
Physician #1
Patient Phone
Physician #1 Address
Relevant Healthcare Information
Daily or more Frequent Agency Services:
Yes
No
if Yes, please describe
Oxygen Dependent: Flow Rate:
Hrs of Use:
Delivery Dev:
Life-Sustaining Infusion
Yes
No
If Yes, please describe
Other IV Therapy
Yes
No
If Yes describe
Patient/Careviver Independent:
Yes
No
Ventilator Dependent:
Yes
No
Dialysis:
Yes:
No
If Yes, please describe
Tube Feeding:
Yes
No
If Yes, please describe
Patient/Caregiver Independent with Self-Administered Medications:
Yes
No
Functional Disabilities (check all that apply) :
Walker/Can
Wheelchair
Hearing Impairment
Visual Impairment
Bed bound
Mental/Cognitive Impairment
Tremors
Personal Emergency Response System:
Yes
No
If Yes, please describe
Back
Next
Emergency Preparedness Kit (dependent upon geographical needs): N/A
Water
3-day food supply
Battery-operated radio
Flash light and dry battery
Other (Specify)
Receipt of Home Safety Evaluation:
Yes
No
(If Yes Date)
/
Month
/
Day
Year
Date
Symptoms to Report
Additional Emergency Guidelines/Instructions
Emergency Plan
Emergency Contact Name
Phone Number
Emergency Contact Relation
If Necessary, l patient will evacuate to :
Relative
Friend
Evacuation contact Name/Phone Number
Next of kin Name / phone number
Hospital of Choice
Hospital of Choice Address
Primary Nurse
Pharmacy
Pharmacy Address/Phone
Fire Department Phone
Police Department Phone
Ambulance Phone
On Call Number
Priority/Acuity Level
Clinician Signature
Clear
Date
-
Month
-
Day
Year
Date
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