... Recommend this page to a friend. See below for the actual form.
Just copy it and place it on your word processor for editing and printing.Being prepared for emergencies with the information you need is something that we all have to be concerned with.
If you are uncomfortable sharing information with your neighbors consider this as an alternative Use this form with all the information that could help emergency personnel save valuable time when treating you, your neighbor, or a loved one. Properly filled out, it contains name, address, birth date, medical histories of surgeries, chronic illness, emergency contacts, physician contacts and medications being taken. It is invaluable for those who are elderly, chronically ill, and live alone. When they can't communicate, it helps the emergency worker in providing proper care.
Fill the form out for each member of the household and have it available should an emergency arise. Enter the information where I make suggestions you do. Make sure each member of your family knows where this information is kept in the event that emergency service personnel need it. You might have a copy in an envelope plainly labeled EMERGENCY MEDICAL INFO stuck on your refrigerator to it is readily accessible. If warranted you might consider having this information on the person of anyone in your family that has a medical condition that could complicate treatment in an emergency.
In every case it's good to be prepared. You never know what will happen. When emergencies strike you have plenty to think about. Have your information ready, it could save your life.
AND NOW OUR EMERGENCY MEDICAL SERVICE FORM IMPORTANT NOTE:
The form below can be copied and printed; compliments of yours truly, Buddy. It was made for a 20" screen on Firefox. Somehow my best looking pages never come out perfect on an IE browser. I prefer Firefox for all my work. If you have IE, you'll have to make your own adjustments after the copy/paste. After copying/pasting it into your processor, you might adjust the length of lines, spacing, margins, and font. Printing and adjusting for your processor will fix any differences. Then you can change the font size to a size more appropriate for you.
(ENTER HERE NAME OF YOUR EMS)
EMERGENCY MEDICAL SERVICES
(ENTER HERE YOUR EMS PHONE NUMBER)
PATIENT MEDICAL INFORMATION SHEET
Date of Form __________/__________/__________
Name
____________________________________________________________________________________
Date of Birth__________/__________/__________
Address___________________________________________________________________________________
City______________________________ State______________ Zip___________________
Telephone ( ) __________ - ____________________
EMERGENCY CONTACT
Name
_____________________________________________________________________________________
Relationship _________________________________
Address___________________________________________________________________________________
City_____________________________ State______________ Zip___________________
Telephone ( ) __________ - ____________________
Family Physician ________________________________________________________________________________
Telephone ( ) _______ - _________________
MEDICAL HISTORY (i.e. Diabetes, Asthma, Heart Attack, etc.)
Illness_______________________________________________________________________________________
Date of Onset __________/__________/__________
Illness_______________________________________________________________________________________
Date of Onset __________/__________/__________
Illness_______________________________________________________________________________________
Date of Onset __________/__________/__________
Illness_______________________________________________________________________________________
Date of Onset __________/__________/__________
Illness_______________________________________________________________________________________
Date of Onset __________/__________/__________
CURRENT MEDICATIONS
Name_______________________________________________________________________________________
Dose __________ Began __________/__________/__________
Name_______________________________________________________________________________________
Dose __________ Began __________/__________/__________
Name_______________________________________________________________________________________
Dose __________ Began __________/__________/__________
Name_______________________________________________________________________________________
Dose __________ Began __________/__________/__________
Name_______________________________________________________________________________________
Dose __________ Began __________/__________/__________
Name_______________________________________________________________________________________
Dose __________ Began __________/__________/__________
( ) Check here if additional medications are being listed on back of form
Any allergies to medications? ( ) Yes ( ) No
Please list, if any:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
PREVIOUS SURGERIES:
Nature______________________________________________________ Date__________/__________/__________
Nature______________________________________________________ Date__________/__________/__________
Nature______________________________________________________ Date__________/__________/__________
Is a current DNR (Do Not Resuscitate) Order in effect? ( ) Yes, ( ) No, Copy Attached ( )
(Note - Out-of-hospital DNR Orders should be no more than 3 months old)
Please list additional medications or any other information that would help us in treatment:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
For emergency ambulance service, see: (ENTER HERE YOUR AMBULANCE SERVICE AND ITS PHONE NUMBER)
Now we return to the ... Navigator ... everyone printed up? |