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)
============================
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
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
