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milahsk; fhz cjTk; gbtk;Identification Form

Basic Information

First name

Surname

Nickname

Date of birth Sex

Language(s) spoken

Home address


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Physical Description

Height feet inches Weight lbs

Eye colour Hair colour

Complexion

Ethnic origin

Identifying Features

Check all that apply

Hearing aid(s) Left Right

Visual aid(s) Glasses Contact lenses

Dentures Upper Lower

Scars, birthmarks, etc. (location and description)

Tattoo(s) (location and description)

Medical Information

Medical condition(s)

Allergies

Medications

Results of not taking medications

OHIP number version

Family doctor’s name

Doctor’s phone #


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To this form, attach a recent, good quality, head and shoulders photograph of the person who may become lost. Replace the photo with an updated version as needed.

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Potential Places to Look

Places where the person may go. For example: previous addresses, previous employment, favourite stores, nearby mall, post office, etc.

For Drivers

Licence plate number

Vehicle colour Vehicle make and model

Emergency Contact Person

Name

Relationship to person with dementia

Home phone #

Work phone #

Cell phone #

Home address

Attach a Recent Photo


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FYW-03-Tami


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Documents

Fog;gj;jpy; my;yJ topjtwpg;Nghdtu;fSf;F ePq;fs; vj;jifa ...findingyourwayontario.ca/wp-content/uploads/2016/03/FYW-A-Practical... · Fog;gj;jpy; my;yJ topjtwpg;Nghdtu;fSf;F ePq;fs;