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"