(1) Client's name.

(2) Social security number or other identifying number.

(3) Current address.

(4) Age, date and place of birth.

(5) Sex.

(6) Marital status.

(7) Date of admission.

(8) Date of discharge.

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

(10) Name, address and telephone number of attending physician and his or her alternate physician.

(11) Medicare and Medi-Cal number, if applicable.

(12) Reason for admission or referral problem.

(13) Type and legal status of admission.

(14) Legal competency status.

(15) Language(s) spoken or understood.

(16) Religious affiliation or preference.

(17) Citizenship.

(18) Parents' marital status.

(19) Father's name and birthplace.

(20) Mother's maiden name and birthplace.

(21) Color of eyes, identifying marks and recent photograph.

(22) Sources of support, including social security, veteran's benefits and insurance.