Emergency Medical Information Form
Download a blank fillable Emergency Medical Information Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Emergency Medical Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1EMERGENCY MEDICAL INFORMATION FORM
Name________________________________________________________________
Phone: Home _______________________ Cell _______________________
Address______________________________________________________________
City_______________________
State__________ Zip_______________
Gender_________ Date of Birth_______/________/_______ Age_______ Height_______ Weight_______ Social Security Number__________________________
In an Emergency notify_____________________________________Relationship_________________Phone: Home ____________________ Cell ________________
MEDICAL INFORMATION
Medical Insurance_____________________________________
Policy #_________________________________
Phone: ______________________________
Blood Type______ Medicare: Yes
No
Medicare #_________________ Do you have a pacemaker? Yes
No
Date of last Tetnus shot______/_____/_____
Physician’s name___________________________________
Specialist?_________________________________
Phone: ______________________________
Physician’s name___________________________________
Specialist?_________________________________
Phone: ______________________________
Allergies__________________________________________
Explain___________________________________________________________________________
Do you wear: Dentures
Bridge(s)
Contacts
Glasses
Hearing Aids
Prosthetics
MEDICAL HISTORY
HYPERTENSION
HEART DISEASE
SEIZURES
ASTHMA
DIABETES
CANCER
G. I. PROBLEMS
LUNG DISEASE
HYPOGLYCEMIA
OTHER_______________________________________________
Any recent surgery? Explain________________________________________________________________________________________________________________
Foreign travel?
When__________________________________
Where___________________________________________________________________
MEDICINES CURRENTLY TAKING
MEDICATION
FOR
DOSAGE
FREQUENCY
PRESCRIBING DOCTOR
1. ___________________
______________________
__________________
__________________
__________________________
2. ___________________
______________________
__________________
__________________
__________________________
3. ___________________
______________________
__________________
__________________
__________________________
4. ___________________
______________________
__________________
__________________
__________________________
5. ___________________
______________________
__________________
__________________
__________________________
Additional Comments:___________________________________________________________ Date Completed or Revised__________________________________
Attach a copy of insurance card. List any herbal remedies, and/or over the counter meds being taken______________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business