Emergency Medical Information

Emergency Medical Information

Name:

Address:

City, State, Zip:

Phone:

Soc. Sec. No:

Employer:

Blood Group:

Medical Disease

Medical Concerns

• Caution: • Other Concerns:

Doctors • Physician names, specialty & telephone number:

Insurance • Primary: • Secondary: Allergies

• List specific medication & type of reaction, such as:

Medical History

• Past surgeries along with dates

• Other important illnesses and health issues

Routine Medications

• Name of each medication, dose & frequency, whether prescription or over the counter (include vitamins if taken regularly)

Other Medications • Name of each medication, dose & frequency, whether prescription or over the counter

Medical Directives • Durable Power of Attorney (where are copies held - – name, address & phone number)

• Living Will (where are copies held – name, address & phone number)

Emergency Contact • Primary: (include relationship, home/work/cell phone numbers)

• Secondary: (include relationship, home/work/cell phone numbers)

• Additional: (include relationship, home/work/cell phone numbers)

--Medicine man 19:29, 30 September 2007 (MDT)