The information on this card is for the use of emergency and general health care professionals to assist them to better serve you and your medical needs.  Make copies for the ER

Name: _____________________________________________________  

DOB MM___DD___YY___

Address:____________________________________________________

City:___________________   State:______ Zip Code:_______________

Home Phone:_________________  Work Phone:__________________

Emergency Contact 1. _________________________________________      Phone:____________

Emergency Contact 1. Relationship:______________________________

Emergency Contact 2. _________________________________________      Phone:____________

Emergency Contact 2. Relationship:______________________________

My Family Doctor is:___________________________________________     Phone:____________

Medial Conditions:  Check only those that apply:

Asthma [  ]  Diabetes [  ]  Tuberculosis [  ]  Emphysema [  ]  COPD [  ]  Heart Disease [  ]

Chronic Renal Failure [  ]  Cancer [  ]  Hypertension (High BP) [  ]  Psychiatric Care [  ]

Seizure History [  ]  Tracheotomy [  ] 

Other:______________________________________________________________________

My Allergies to Medications are:_________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Current Medications are:

Name:                                    Dosage    How I take it    Times per Day

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