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 this out & have ready for paramedics and ER doctors to quickly help you. Keep in your wallet/purse., glove box, Vial of Life.   Keep updated.