Medical Emergency Information
[Name]
[DOB]
Updated: [date]
Who to call for assistance and support
[Name & Phone Number]
[Name & Phone Number]
Medical Conditions
| Condition | Onset Date | Notes / Prescribed by (Doctor & Phone) |
|---|---|---|
| [Medical Condition #1] | [Onset Date] | [Prescribed by Dr. Name — Phone #] |
| [Medical Condition #2] | [Onset Date] | [Prescribed by Dr. Name — Phone #] |
| [Medical Condition #3] | [Onset Date] | [Prescribed by Dr. Name — Phone #] |
| [Medical Condition #4] | [Onset Date] | [Prescribed by Dr. Name — Phone #] |
Add additional conditions on a separate sheet if needed.
Past Surgeries
| Surgery | Date | Notes / Surgeon |
|---|---|---|
| [Surgery #1] | [Date] | [Notes / Surgeon] |
| [Surgery #2] | [Date] | [Notes / Surgeon] |
| [Surgery #3] | [Date] | [Notes / Surgeon] |
| [Surgery #4] | [Date] | [Notes / Surgeon] |
Medications (as of [date])
| Medication | Start Date | Prescribed by (Doctor & Phone) |
|---|---|---|
| [Medication #1] | [Start Date] | [Dr. Name — Phone #] |
| [Medication #2] | [Start Date] | [Dr. Name — Phone #] |
| [Medication #3] | [Start Date] | [Dr. Name — Phone #] |
| [Medication #4] | [Start Date] | [Dr. Name — Phone #] |
Drug Allergies
[List drug allergies or N/A]
Notes / Special Precautions
[Special precautions, special notes — e.g., Do not resuscitate, mobility issues, pacemaker, etc.]
Attachments (recommended)
Primary Care Physician
[Practice Name, Address, Phone]
Other Physicians / Specialists
| Physician / Practice | Address / Phone |
|---|---|
| [Other Physician #1] | [Address / Phone] |
| [Other Physician #2] | [Address / Phone] |
| [Other Physician #3] | [Address / Phone] |
Advance Directives
Healthcare POA: [Who, then who] — Living Will: [Yes / No / Location of document]
Burial Information
[Burial preferences / instructions]
Identification & Insurance
XXX-XX-[last4]
[Name, Number, Expiration]
[Company, Policy, Subscriber ID, Group No.]
[Company, Policy #]
Contacts
[Name & Phone]
[Name & Phone]
Signature / Authorization
[Signature — sign above dashed line]
[Date]
By signing, I confirm that the information above is accurate to the best of my knowledge.
