Information Sheet

“Vinh Tuyet family's BAXH program”

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INFORMATION SHEET

1. Personal information for severe disabilities, incurable diseases, mental illness, and lonely elderly people:

- Holy name, full name: ………………………………, Year of birth: …………

- Address: (family, parish): ………………………………………………..

- Medical status: ………………………………………………………..

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2. Family information:

- Describe family economic situation: …………………………………………

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- Full name of caregiver: ……………………………., Year of birth: …………

- Relationship with patient: …………………, Contact phone: …………………

3. Date of establishing information: ……../ ……./201…

4. Attachment: 2 9 x 12 photos (1 photo of patient, 1 photo of current house)

Note:  Each information sheet is for 1 patient only