EMERGENCY INFORMATION

PERSONAL EMERGENCY INFORMATION

PERSONAL INFORMATION FOR EMERGENCIES

Use a pencil to fill out one card for each person.

Fold card and insert it in red magnetic pouch.

Place the red pouch on the refrigerator door.


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Name: __________________________________________________________   Sex:  M __  F __

Address: ________________________________________________________

                ________________________________________________________    (Recent Photo)

Doctor:   ________________________________  Phone: ________________

Native Language: ________________________________________________

Emergency Contact: _____________________________________________

    Relationship __________________________  Phone: ________________


MEDICAL CONDITIONS            (Check All That Exist)

__    No Known Medical Conditions

__    Abnormal EKG

__    Adrenal Insufficiency

__    AIDS

__    Alcohol Addiction

__    Alzheimer’s  Disease

__    Angina

__    Anxiety

__    Asthma

__    Behavior

__    Bleeding Disorder

__    Blind

__    Cancer

__    Cardiac Dysrhythmia

__    Cataracts

__    Congestive Heart Failure

__    Clotting Disorder

__    COPD

__    Coronary Bypass Graft

__    Deaf

__    Dementia

__    Depression

__    Diabetes / Insulin Dependent

__    Diabetes / Non-Insulin

__    Drug Addiction

__    Epilepsy / Seizures

__    Eye Surgery

__    Glaucoma



ALLERGIES

__    No Known Allergies

__    Aspirin

__    Barbiturites

__    Codeine

__    Demerol

__    __________________________

__    __________________________

__    Environmental

__    Horse Serum

__    Insect Stings

__    Latex



MEDICAL DATA AS OF        Month   ______________    Year   ___________    Blood Type  ________


MEDICATIONS

Medical Problem                        Medication                          Dosage          Frequency

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________

___________________________    _______________________    ___________    ____________


RECENT SURGERY    _______________________________    Date    ___________________

                                     _______________________________    Date    ___________________                     


IMMUNIZATIONS                      

Flu Shot                       Date    ________________    Location  ____________________________________

Pneumonia Shot         Date    ________________    Location  ____________________________________

Other                            Date    ________________    Location_____________________________________



EMERGENCY CONTACTS

NAME:    ___________________________________________________________________________________

Address:    _________________________________________________________________________________

Relationship    ______________________________________________    Phone    _____________________


NAME:    ___________________________________________________________________________________

Address:    _________________________________________________________________________________

Relationship    ______________________________________________    Phone    _____________________


Medical Insurance Company    _______________________________    Policy # _____________________

Other Medical Insurance Co     _______________________________    Policy # _____________________

Medicare #  _________________________________    Medicaid  ___________________________________

Date Of Birth    ______________________________    Religion    ___________________________________

Special Conditions / Remarks     _____________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

DNR     (Do Not Resuscitate)   YES ____    NO ____    Location __________________________________

Health Care Proxy On File At  ________________________________________________________________

Living Will On File At   _______________________________________________________________________

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__    Hard Of Hearing

__    Heart Valve Prosthesis

__    Hemodialysis

__    Hypertension

__    Internal Defibrillator

__    Irregular Heart Rhythm

__    Kidney Failure

__    Laryngectomy

__    Leukemia

__    Lung Disease / Emphysema

__    Lymphomas

__    Malignant Hypothermia

__    Memory Impaired

__    Mental Illness

__    Mental Retardation

__    Myasthena Gravis

__    Oxygen Use

__    Pacemaker

__    Previous Heart Attack

           Date: ___________________

__    Seizure Disorder

__    Sickle Cell Anemia

__    Stroke

__    Tobacco Use

__    Vision Impaired

__    Other  ____________________

        __________________________

        __________________________ 
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__    Lidocaine

__    Morphine

__    Novocain

__    Penicillin

__    Sulfa

__    Tetracycline

__    X-Ray Dyes

__    Other

__    __________________________

__    __________________________

__    __________________________

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The content on AsYouAge.com is provided as a courtesy for our site visitors. The information, resources, links, advertisements and other material on As You Age does not constitute a professional opinion or advice; nor does it constitute an endorsement of any organization or the information, products and/or services they may offer. As You Age reviews and updates its content regularly when new and relevant information is made available. This information is neither intended nor implied to be a substitute for professional advice in any area: health, medical, legal, insurance, financial or any other area. Always seek the advice of your physician or qualified health provider, or caregiver, attorney, financial, insurance expert or other specialist prior to starting, dropping or changing your current program or have questions or concerns  regarding current or anticipated issues.


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As You Age

Personal Emergency Information

The content on AsYouAge.com is provided as a courtesy for our site visitors. The information, resources, links, advertisements and other material on AsYouAge does not constitute a professional opinion or advice; nor does it constitute an endorsement of any organization or the information, products and/or services they may offer.

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