Louisville Metro Medical Needs Registry

Welcome to the Louisville Metro Medical Needs Registry survey page. This registry is designed to better assist persons with medical dependencies in the event of an emergency. Please note that any information you provide is voluntary and will be kept confidential among first responders.

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* 1. Contact Information

Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

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* 2. Gender:

Male

Female

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* 3. Age (please choose the appropriate range):

0 - 17

18 - 29

30 - 39

40 - 49

50 - 59

60 - 69

70+

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* 4. Do you require a caregiver?

Yes

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* 5. Will a caregiver/companion accompany you to the shelter?

Yes

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* 6. Caregiver's Information:

Name of Agency he/she belongs to:

Name:

Phone Number:

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* 7. Primary Care Physician Information:

Name:

Phone Number:

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* 8. Do you have a service animal?

Yes

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* 9. List all medical supplies you use on a regular basis:

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* 10. List all allergies:

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* 11. Is this the first time you have filled out this survey?

Yes

If this is not the first time, please explain why you are filling out this survey again.