Farmington Police Department

Information Sheet for the Individual with Alzheimers for Police and Emergency Response Agencies
Due to the unique nature of this disability it is stressed for individuals afflicted with the disease and their local emergency response
agencies to work together so that crucial information about the individual is available in the case of an emergency.

Last Name:

____________________

First Name:

__________________________________

Birth Date:

____________________

Race:

__________________________________

Sex:

____________________

Height:

__________________________________

Weight:

____________________

Hair Color:

__________________________________

Eye Color:

____________________

 

 

 

 

Other

__________________________________

Current photo available?:   

 

YES    NO

  

Features:

__________________________________

 

 

 

 

 

 

 

 

 

Medical Conditions

_________________________________________________________

Medical Cautions

_________________________________________________________

 

_________________________________________________________

Medical Allergies

_________________________________________________________

 

_________________________________________________________

 

Care Provider:

______________________________________

Address:

______________________________________

Phone:

______________________________________

Physician:

______________________________________

Phone:

______________________________________

 

 

 

  

Current Photo