SOS Health Care, Inc. 843.449.0554 phone 843.497.4861 fax
Monique Clement 843-602-8840 cell
Date___________
Client Full Name____________________________________________________________
Client Address______________________________________________________________
Care Givers Name(s)_________________________________________________________
phone#__________________cell#____________________email_____________________
Client Information:
Birthdate:_________________________Race:__________________Sex:_______________
Height_________Weight_________Eye Color_________Glasses or Contacts Y/N_ ______
Hair Color_________Hair Style__________Bald Y/N_________Hearing Aid Y/N_______
Is your member a runner? y/n, if yes explain______________________________________
Have you ever had to call the police? If yes, explain________________________________
Facial Hair: mustache, beard, sideburns etc.______________________________________
Scars, marks and or tattoos:___________________________________________________
Primary Language Spoken_________Secondary Language Y/N______________________
Verbal or Non-Verbal______________
Sign Language Y/N Does client use any other form of communicating Y/N_____________

Does client drive or have access to a vehicle? (If yes, describe vehicle and plate number):
___________________________________________________________________________
Medical Diagnosis: (you will need to provide a copy of your diagnosis)
__________________________________________________________________________
Medication:_________________________________________________________________
___________________________________________________________________________
Medical History:_____________________________________________________________
___________________________________________________________________________
Attending Physician Name & Number:___________________________________________
Please describe the best way to approach client if he/she is lost________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
If any, name a few key words or phrases to get clients attention (if they have a favorite food, song, friends name etc)__________________________________________________________
_____________________________________________________________________________
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Comments or Questions:_________________________________________________________
_____________________________________________________________________________
Horry County Public Safety Sponsor