Emergency Medical Service Form

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.

(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)