Emergency Medical Information Form printable pdf download

Emergency Medical Information Form

EMERGENCY MEDICAL INFORMATION FORM

Complete this form and add it to your “Emergency-Go-Bag.” Your bag should contain bottles of medicine

you are currently taking, any advanced directive paperwork, and this form to help your health care

providers such as EMS and your emergency room physicians and nurses treat you.

Today’s Date: _____________ Your Date of Birth: __________________ Blood Type:________

Your Name:____________________________________________________________________

Address:______________________________________________________________________

City:________________________________ St:_________________ Zip:___________________

Home Phone #:_________________________ Cell Phone #:_____________________________

Is your primary language English: Yes No If no, what is your primary language:___________

Physician and Medical Specialists Information

Primary Care Physician Name:_____________________ Phone: _________________________

Specialist Name: ________________________________ Phone:_________________________

Specialist Name_________________________________ Phone: _________________________

Do you have any advanced directives? (circle all that apply):

Living Will

Do Not Resuscitate

Allow Natural Death

Emergency Contacts, Caregivers or Healthcare Surrogate

Name #1: ___________________________________ Relationship:______________________

Home Phone #: ______________________________ Cell Phone #:_______________________

Address: ___________________________________ State: _____ Zip: ____________________

Name #2: ___________________________________ Relationship: ______________________

Home Phone #: ______________________________ Cell Phone #:_______________________

Address: ____________________________________ State: _____ Zip: ___________________

Emergency Medical Information Form