HD Helpful Forms
Personal Emergency Information

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In Case of An Emergency

 

Date Form Completed: _________

Current Age: ____

 

INFORMATION IS FOR:

Last Name: _________________________
First Name:
_________________________
Middle Initial:
_______________________
Social Security Number:
____-____-_____
Blood Type: _______
Medications Allergic To: (See Below)

 

EMERGENCY PHONE NUMBERS (besides 911);

Fire: ________________
Police:
______________
Ambulance:
__________
Hospital:
____________

 

DIRECTIONS

To provide Emergency Personnel directions to

your home:

 

Subdivision or Condo Association: _______________________
Nearest Intersections:
_______________________________
Nearest Major Roads
: ____________________________

 

OTHER PERSONAL INFORMATION

Date of Birth: ________________
House Number
________________
Street:
________________
City
________________
State
________________ Zip_________________
Home Phone # (
___) ____ - ______
Driver's License #
_______________
Height:
_________     Weight: ________
Hair Color:
_________ Eyes: ________
Pacemaker:   ( ) yes ( ) no
Eye Glasses:  ( ) yes ( ) no
Contact Lens: ( ) yes ( ) no
False Teeth:   ( ) yes ( ) no
Birthmarks or Scars/Where:
________________

 

PHYSICIAN(s):

Primary Care Doctor___________________
City/State:
__________________________
Telephone Number
___________________
Emergency Service
___________________
Specialist (identify)
City/State:
___________________________

Telephone Number ____________________
Emergency Service
____________________

 

HOSPITAL(s) -

Name the preferred hospital or one covered by

your insurance. If necessary transport me to the

following hospital:


________________________________________

 

 

INSURANCE:

Primary
Carrier (i.e. Prudential etc)
__________________

Policy #
______________Group #___________
Policy Holder's Name
: _____________________
Phone:
_______________________________

Pre-Certification Phone: ___________________

Secondary (Medicaid, Medicare, etc.)
Carrier
________________________________
Policy #
________________Group #__________
Policy Holder's Name:
______________________
Phone:
_________________________________

Pre-Certification Phone: _____________________

 

EMERGENCY CONTACT(s)

Name ____________________________
Relationship to you
_________________
Phone Number
_____________________
Cell Phone/Pager
___________________

Name
____________________________
Relationship to you
_________________
Phone Number
_____________________
Cell Phone/Pager
___________________

 

OTHER PERTINENT DOCUMENTS/INFORMATION

If applicable, attach document to this sheet

Living Will              ( ) yes ( ) no
Do Not Resituate    ( ) yes ( ) no
Organ Donor:         ( ) yes ( ) no

Medical Power of Attorney:
Person Designated
:_____________________

Telephone Number
_____________________
Cell Phone/Pager #
_____________________

 

CHRONIC MEDICAL CONDITION(s)

(Identify, i.e. Huntington's Disease, Cancer, Congestive

Heart Failure, Diabetic I or II, Emphysema, Epilepsy, Seizures,

Kidney or Liver disease etc.)

Condition:
_______________

Diagnosed:
______________
Specialist:
_______________

Condition:
_______________
Diagnosed:
______________
Specialist:
_______________

 

OTHER MEDICAL CONDITIONS:

(Identify i.e. Hearing Loss, Blind, Anemia, Thyroid Disease,

High Blood Pressure, etc.)

Condition:
_______________

Diagnosed:
______________
Specialist:
_______________

Condition:
_______________
Diagnosed:
______________
Specialist:
_______________

 

VACCINATIONS

Year of last vaccination
___Tetanus/diphtheria
___Pneumococcal vaccine
___Flu vaccine
___Measles, mumps, rubella
___Polio
___Varicella (chickenpox)
___Hepatitis A
___Hepatitis B

 

ALLERGIC TO - DO NOT GIVE:

(list everything i.e. Morphine causes rash, etc.)

Allergic to:
_________________

Reaction:
_________________

Allergic to:
_________________
Reaction:
_________________

Allergic to:
_________________
Reaction:
_________________

 

SPECIAL INSTRUCTIONS:

Identify i.e.: Keep Calm/Tends To Hyperventilate

When Excited-Seizure Prone; Do Not Use Restraints;

Keep Head Elevated/Swallowing Difficulties, etc.
__________________________________

__________________________________
__________________________________
__________________________________

 

CURRENT PRESCRIPTION MEDICATION(s)
List or use the Medication Form and say

"See Attached"

 
ADDITIONAL CONTACTS
(To Be Made By Family, Not EMS,I.e.
employer, other emergency contacts,
funeral homes, clergy, etc.)

Organization:
___________________
Person To Contact
_______________
Telephone No.
__________________

Organization:
___________________
Person To Contact
_______________
Telephone No.
__________________

Organization:
___________________
Person To Contact
_______________
Telephone No.
__________________

THIS PERSON IS UNDER AGE 18
 

This form is for my child, under age 18. Permission is

granted to treat my child in an emergency 

 

( ) Yes 

( ) No, contact me prior to treating.

Parent Name:
_____________________________

Emergency Telephone Number:
_______________

Signature:
________________________________