Checklist and Personal Assessment

To print this emergency Checklist and Personal Assessment please click HERE then choose language and hit print screen .

During an emergency, this checklist will enable emergency responders to better assist you.

I am able to:

Hear
See
Walk without help
Walk with help
Prepare my meals
Feed myself
Dress myself
Sit without help
Sit with help
Wash/bath without help
Wash/bath with help
Sanitary needs without help
Sanitary needs with help

I will need specific help with (explain):
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Important personal information

List your prescription number, name and purpose of each medication (i.e., #34567/insulin/diabetes)

Prescription #: _____________________________________
Name of medication: _____________________________________
Purpose: _____________________________________

Doctor(s): _____________________________________
Phone(s): _____________________________________
Special equipment I use: _____________________________________
Special sanitary aids: _____________________________________
Allergies: _____________________________________
Other special needs: _____________________________________
Special diet: _____________________________________

Health card #: _____________________________________
Private medical: _____________________________________
Policy #: _____________________________________
Neighbourhood contact: _____________________________________
Out-of-town emergency contact: _____________________________________
School contact: _____________________________________
Household pet care: _____________________________________
Veterinarian phone: _____________________________________

Local emergency management contact (for your area):
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Personal support network contact list (family members, attendants, neighbours, etc.)

Name: _____________________________________
Relation: _____________________________________
Address: _____________________________________
Phone (home): _____________________________________
Phone (business): _____________________________________