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Emergency Medical Info Form

Name  
Address  
Address, cont'd  
City  
State/Prov.       Postal Code  
Home Phone       Work Phone  
Email  
Date of Birth       SSN/ID#  
Blood Type       Prior Transfusion Reaction (describe)
   
_______________________________________________________________________________
  Contact Lenses?     Dentures?     Diabetic?     Epileptic?
Allergies to
medications?
(list)
Medications
taking now?
(list)
Other medical
conditions?
(list)
Surgeries or
Hospitalizations?
(year, what done,
location)
_______________________________________________________________________________
Insurance Co.   (leave blank if no insurance)
 
Group number  
Policy number  
 
Primary Physician and/or Medical Treatment Facility:
Physician Name
Facility, Clinic,
Group or Hospital
Address
City
State/Prov.     Postal Code  
Phone
Next of Kin or person to be notified in an Emergency:
Name
Address
City
State/Prov.     Postal Code  
Phone
E-mail
Other person(s) to be notified in an Emergency:
Name
Address
City
State/Prov.     Postal Code  
Phone
E-mail

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Notes:

  • Stick a copy of this form where someone else can easily find it. I keep a copy in the inside pocket of my motorcycle leathers. A wallet is another good place for one.
  • You may print this form as-is, and fill it in by hand — or you can fill it in on the computer before printing it.
  • This form will print neatly on two pages. If you feed a single page into your printer, you can print one side, then reinsert the page (downside up) to print the 2nd page on the back of the first.
  • You can also use the PRINT SETUP menu in your Web browser to change the print margins, and remove the default header and footer lines. Or you can just trim off the excess edges before folding it up.

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