Identifying Features. Check all that apply: Hearing aid(s):. Left. Right. Visual aid(s):. Glasses. Contact lenses. Dentu
Identification Kit
Fill out this form and keep it in a central location (for example, a hall table, refrigerator door) Keep an extra copy of this kit for police. If the person goes missing, you will immediately have this valuable information to help police with their search.
Basic Information First name:________________________ Surname:_______________________ Nickname:___________________________________________________________ Date of birth:___________________________ Sex:_______________________ Language(s) spoken:__________________________________________________ Home address:_______________________________________________________ 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):____________________________________ ___________________________________________________________________ Identification Kit - 2
Recent Photo Replace with an updated version as needed.
Tape a recent, good quality, head and shoulders photograph of the person who may become lost here.
Medical Information Medical condition(s):__________________________________________________ ___________________________________________________________________ Allergies:____________________________________________________________ Medications:_________________________________________________________ Results of not taking medications:_______________________________________ ___________________________________________________________________ OHIP #:___________________________ version:_________________________ Family doctor’s name:_________________________________________________ Doctor’s phone number:_______________________________________________ Identification Kit - 3
Potential Places to Look Places where the person may go. For example: previous addresses, previous employment, favourite stores, nearby mall, post office, etc. 1)_________________________________________________________________ 2)_________________________________________________________________ 3)_________________________________________________________________ 4)_________________________________________________________________ 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:_______________________________________________________ ___________________________________________________________________
