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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