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A copy of this form, and all
attachments, should be visible on your refrigerator, a copy put in the glove compartment of all vehicles,
one provided to school for child's records, one provided to your employer
for your personal file, and a copy provided to your primary care physician. |
One form should be filled out for each member of your
family. Click above if you would like this form in a Word Document suitable forfilling out and printing.
Jean |
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:________________________________ |
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