EMERGENCY MEDICAL PROFILE FORM
NAME: ________________________________________________________________________ Updated ___/___/___
DOB: _____/_____/_____ SSN: _______-______-________ HEIGHT: _________ WEIGHT: ________ lbs BLOOD TYPE: _________
RESIDENCE ADDRESS: _________________________________________________________________________________________________
HOME PHONE: ______-______-_________ DRIVER LICENSE # ____________________
WORK (company, job title, phone): _________________________________________________________________________________________
MARRIAGE & CHILDREN: ______________________________________________________________________________________________
________________________________________________________________________________________________________________________
MAJOR MEDICAL HISTORY (year and summary):
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
VACCINATIONS (year & type): ___________________________________________________________________________________________
SMOKE
: ______________ ALCOHOL: ____________________ CAFFEINE: ______ RECREATIONAL DRUGS: ____________MEDICATIONS (name, frequency, dose, what for)
:________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
MEDICINES & FOODS ALLERGIC TO: ___________________________________________________________________________________
OTHER ALLERGIES: ___________________________________________________________________________________________________
ORGAN DONOR: _______________________________ Normal BP: _______/_______ Pulse: ________
MEDICAL DEVICES/IMPLANTS: ________________________________________________________________________________________
PREFERRED HOSPITAL AND/OR CLINICS: ______________________________________________________________________________
REGULAR PHYSICIANS (specialty, name, phone, address):
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
DIRECTIVE TO PHYSICIANS (no, yes, location): ____________________________________________________________________________
DNR (Do Not Resuscitate) ORDER: (no, yes, location): _________________________________________________________________________
MEDICAL POWER OF ATTORNEY (who, contact info, document location): _____________________________________________________
KEY CONTACTS (relationship, name, home phone, other phone):
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
INSURANCE (company, policy type, policy ID, contact number):
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
INSTRUCTIONS: Fill out & have ready for paramedics & ER docs to quickly help you. Keep in wallet/purse, glove box, Vial of Life. Keep updated