Emergency Medical History Form printable pdf download

EMERGENCY MEDICAL HISTORY

This form is for Emergency use when Parent/Guardian/Representative is not immediately available but the

individual needs emergency medical assistance. For use by Emergency Personnel Only.

NAME: _________________________________ Nickname: _____________________

Birth Date: _____________________

Home Address: ________________________________ Home/Work Phone: ________

Parent/Guardian: _______________________ Address: ________________________

Phone Numbers: _________________________________________________________

Primary Language: ______________________

EMERGENCY CONTACT NAMES, RELATIONSHIP, and PHONE NUMBERS:

#1______________________________________________________________________

#2______________________________________________________________________

#3______________________________________________________________________

Physicians

Primary Care Physician: _________________________________________________

Emergency Phone: ___________________________ Fax: _______________________

Current Specialty Physician: ______________________________________________

Specialty: ___________________________

Emergency Phone: ___________________________ Fax: _______________________

Current Specialty Physician: ______________________________________________

Specialty: ___________________________

Emergency Phone: ___________________________ Fax: _______________________

Short Medical History

Diagnosis: ______________________________________________________________

Current Medications (

: ______________________________

Name, Dose, Frequency given)

ALLERGIES (

): _____________________________________________________

Drug

________________________________________________________________________

ALLERGIES (

): _____________________________________________________

Food

________________________________________________________________________

Latex Allergy: Yes ______ No _____

Pg. 1 of 2 Emergency Medical History

Special Needs Resource Project L.L.C.

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Emergency Medical History Form