(1) Name and Social Security number or other identifying number.

(2) Current address.

(3) Age and date of birth.

(4) Sex.

(5) Marital status.

(6) Date of admission.

(7) Date of discharge.

(8) Name, address and telephone number of next of kin, guardian, authorized representative and agency responsible for client.

(9) Name, address and telephone number of attending physician and of the podiatrist, dentist or clinical psychologist, if such practitioner is primarily responsible for the treatment of the client.

(10) Name, address and telephone number of the designated alternate physician.

(11) Admission diagnosis, known allergies and final diagnosis.

(12) Medicare and Medi-Cal numbers when appropriate.

(13) Reason for admission or referral problem.

(14) Type and legal status of admission.

(15) Legal competency status.

(16) Language spoken or understood.

(17) Information relevant to religious affiliation.

(18) Citizenship.

(19) Parents' marital status.

(20) Medication history, as required by Section 76589(a)(5).