emergency information form

Date completed:______________ by whom?________________________

(if not the person described, what relation to the person?_________________)

Name_______________________________________

address_______________________________________

city_____________________ state_____________ZIP___________

home phone_________________ cell phone___________________________ work phone_______________

birthdate_______ / __________ / _________

circle: male / female       blood type_______

hair color________________ eye color___________ dentures (circle none or upper / lower)

describe identifying marks/tattoos:

normally unequal pupils: circle NO or describe, including which one is usually a different size:

native language if not English__________________ last four digits of social security number_______________

health plan name_______________ member number_______________________

doctor name____________________ doctor phone number_________________

dentist name________________ dentist phone number___________

hospital preference_______________________ (Have you been a patient there? circle yes / no)

Allergies to medications: circle none or list:

What type of reactions have you experienced when you were exposed?

Allergies to food, plants, insects: circle none or list:

What type of reactions have you experienced when you were exposed?

Medications (including prescription, over-the-counter, herbal): list dosage and frequency

Medical conditions and/or Are you under a doctor’s care for anything? (see list below)
diabetic       epilepsy      asthma     high blood pressure     low blood pressure     hemophilia      emphysema     heart murmur     AIDS     glaucoma      hypoglycemia     

Pregnant circle no/ yes: due date _______ / __________ / _________ Complications? circle none or describe:

stroke: circle none or give details:

cancer: circle none or give details:

cardiac history: circle none or give details:

Do you wear a medic alert tag? (wrist/neck/watch/ or describe__________________________)

Date of last Tetanus shot _______ / __________ / _________ or circle: got one but don’t remember when or none

Date of last flu shot _______ / __________ / _________ or circle: this season/ last season or none

List other vaccinations/ immunizations and dates if you know them (examples: HEP B, diptheria, pertussis, HPV, MMR, varicella, shingles, poliovirus, Hep A, typhoid)

Date of last hospitalization _______ / __________ / _________ for what?__________________

(complications?)

Date of last surgery _______ / __________ / _________ for what?______________________

(complications?)

Date of last significant illness _______ / __________ / _________ what illness? _________________

(complications?)

Do you have a directive? circle yes / no (where is it?)

Do you have a pacemaker? circle yes / no brand/model number:

Do you have a hearing aid? circle yes / no brand/model number:

List hearing difficulties: circle none or describe:

List vision difficulties: circle none or describe: (contact lenses/eyeglasses/computer use glasses/reading glasses)

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Keep up your needed vaccinations. A tetanus inoculation, for example, is good for about ten years. (During spring 2001 flooding in the Midwest, raw sewage in the flood waters coincided with a national shortage of tetanus vaccine.)

Recommended vaccinations for all ages, professions, travelers can be found at:

http://www.cdc.gov/vaccines/schedules/index.html