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EMERGENCY INFORMATION FORM

Name: __________________________________________________As of Date:________

Address: _________________________________________________________________

Phone(s) _________________________________________________________________

Email address: _______________________________

Born: Date: ______________ Where: _______________________ Age: _______

Sex: ______________________ Race: ____________ Hair Color: _______________

Medical

Height: _____ Weight: ______

Eyes    Blind: ______ Glasses: ______Contacts: _____

Mouth   Dentures: __________  Other Problems: ______________________________

Ears    Mute: ________ Deaf: _______ Hearing Aid: ________ Sign Language_________

Native Language:____________________________            Religion: _______________

Social Security Number: _______________________

Doctor’s Name: _______________________________________ Phone: _______________

Insurance: ________________________________________________

Medications (include  Name, Dosage, Frequency, Why taking it, Dr. who prescribed):___________________________________________________________________________

____________________________________________________________________________________

Medications/Location: ________________________________________________________

Allergies to Medications: ______________________________________________________

Other Allergies: ______________________________________________________________

Pacemaker: _________         Organ Donor: ______________

Yes or No to:

____ AIDS Anemia Arthritis
____ Asthma Cancer Diabetes
____ Dialysis Epilepsy Glaucoma
____ Heart Condition Hepatitis High Blood Pressure
____ Respiratory Sickle Cell Stroke
____ Tuberculosis

Additional Information:_____________________________________________________

____________________________________________________________________________

Advance Directives/Location: __________________________________________________

Local Emergency Contact: _______________________________

Work/Phone of Contacts: ________________________________________________________________
________________________________________________________________________________________

Family(for each provide name, relationship, address, phone numbers, email address)

Partner:______________________________________________________________

Children:_____________________________________________________________

Parents:______________________________________________________________

Other:________________________________________________________________

Please keep this information in or on your refrigerator and update it at least once a year.
When you are away, please leave dates, location, and contact information on your refrigerator
door. 

Form Date: 12/28/09, revised 6/2/2016

Permanent link to this article: http://oloc.org/resources-2/alapine/emergency-information-form/