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