Emergency Information for First Responders
The following form is for pertinent information that can be provided to First Responders in the event of an emergency. This form is in compliance with "Logan's List" established in GA Code § 38-3-182
Select one
*
I am filling this form out on myself.
I am filling this form out on behalf of someone else.
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Your information
You have selected you are filling this form out on behalf of someone else, first, we need some information on you, the person filling out this form.
Your Name
First Name
Last Name
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.
Relation to Individual
Parent
Spouse
Child
Sibling
Other
Is the individual a minor? (under the age of 18)
Yes
No
Are you their legal guardian?
Yes
No
Legal Guardian's Name
First Name
Last Name
Legal Guardian's Phone Number
Please enter a valid phone number.
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Patient Information
Legal Name
*
First Name
Last Name
Gender
Male
Female
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the patient attend work or school?
Yes
No
Please list work or school information here:
Business or School Name
Street Address
City
State / Province
Postal / Zip Code
Emergency Contact
List Emergency Contacts for the above listed individual.
Emergency Contact #1
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to Individual
Please Select
Spouse
Parent
Child
Sibling
Caregiver
Other
If other, please specify
Emergency Contact #2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to Individual
Please Select
Spouse
Parent
Child
Sibling
Caregiver
Other
If other, please specify
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Home Information
The following information is optional but will help first responders when responding to an emergency.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are house number clearly marked?
Yes
No
Gate Code
Door Code
Lock Box Information
Provide a brief description of the home:
Where is this individuals bedroom located in the home? (this information is used in the event of a fire)
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Pertinent Medical Information
Please fill out the following information about the person listed on the previous page
Please list medications
Please list food and medication allergies
Chronic Medical Conditions
Arthritis
Congestive Heart Failure
Diabetes
Hepatitis (Chronic Viral B & C)
Asthma
HIV/AIDS
Atrial Fibrillation
Hyperlipidemia
Hypertension (High blood pressure)
Cancer
Ischemic Heart Disease
Chronic Kidney Disease
Osteoporosis
Chronic Obstructive Pulmonary Disease
Schizophrenia and Other Psychotic Disorders
Depression
Stroke
Other Medical Conditions
Hearing Impairment (Deaf)
Yes
No
Visual Impairment (Blind)
Yes
No
Any conditions that require no lights and sirens? (ie. autism, epilepsy)
*
Light and Sirens acceptable
No Lights and Sirens
Dementia
*
Yes
No
Special Needs (i.e. Autism)
*
Yes
No
Home Oxygen
*
Yes
No
Do you have any mobility limitations?
*
Yes
No
Please specify the mobility limitations:
Do you have any other medical devices that require a power source?
*
Yes
No
Please specify
Current Date
-
Month
-
Day
Year
Date
Date After 2 Years
-
Month
-
Day
Year
Date
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Dementia Questionnaire
Select one that best describes the patient:
Mild confusion and forgetfullness, short-term memory effected
Difficulty distinguishing time, place, and person. Some language difficulties.
Nearly complete loss of judgement reasoning, and loss of some physical control.
Does the patient tend to "wander" or go for walks?
Yes
No
Where do they often go?
Does the patient drive?
Yes
No
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Autism Questionnaire
Is the person verbal?
Yes
No
Please Describe
Does the person have seizures?
Yes
No
Please Describe
Is the person noise sensitive?
Yes
No
Please Describe
Is the person touch sensitive?
Yes
No
Please Describe
Is the person likely to run away?
Yes
No
Please Describe
Where do they tend to go?
Does the person have a history of violence?
Yes
No
Please Describe
Are there any fears, anxieties or triggers which upset the person?
Yes
No
Please Describe
Are there any fears, anxieties or triggers which upset the person?
Yes
No
Please Describe
Please let us know any other information pertaining to special medical conditions that may be pertinent to First Responders:
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If there is any other information you wish to provide, you can do so in the space below:
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Acknowledgement
Signature
Submit
Submit
Should be Empty: