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
KEEP THE PRESCRIPTIONS REFILLED. You might not be able to get refills for days after a earthquake power outage or a coronavirus outbreak when people are asked to stay at home.
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 an Advanced 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:
https://www.cdc.gov/vaccines/?CDC_AAref_Val=https://www.cdc.gov/vaccines/schedules/index.html
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a Critical Incident Stress Guide is at:
https://www.osha.gov/SLTC/emergencypreparedness/guides/critical.html
advance care directives has info and a link to where you can get a free one.
Pandemic flu
earthquake home hazards survey
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The author of this webpage, (written as a homework reading assignment for my students), does not give any warranty, expressed or implied, nor assume any legal liability or responsibility for the accuracy, completeness, or usefulness of any information, product, or process included in this website or at websites linked to or from it. Users of information from this website assume all liability arising from such use.