EMERGENCY MEDICAL PROFILE FORM
NAME: ________________________________________________________________________ Updated ___/___/___
DOB: _____/_____/_____ SSN: _______-______-________ HEIGHT: _________ WEIGHT: ________ lbs BLOOD TYPE: ______
RESIDENCE ADDRESS: ________________________________________________________________________________________________
HOME PHONE: ______-______-_________ DRIVER LICENSE # ____________________
WORK (company, job title, phone): ________________________________________________________________________________________
MARRIAGE & CHILDREN: _____________________________________________________________________________________________
________________________________________________________________________________________________________________________
MAJOR MEDICAL HISTORY (year and summary):
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
VACCINATIONS (year & type): ____________________________________________________________________________________________
SMOKE
: ______________ ALCOHOL: ____________________ CAFFEINE: ______ RECREATIONAL DRUGS: ____________MEDICATIONS (name, frequency, dose, what for)
:________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
MEDICINES & FOODS ALLERGIC TO: ____________________________________________________________________________________
OTHER ALLERGIES: ____________________________________________________________________________________________________________
ORGAN DONOR: _______________________________ Normal BP: _______/_______ Pulse: ________
Medical Devices/Implants: ________________________________________________________________________________________
Preferred Hospital AND/OR CLINICS: _______________________________________________________________________________________________
REGULAR PHYSICIANS (specialty, name, phone, address):
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
DIRECTIVE TO PHYSICIANS (no, yes, location): ___________________________________________________________________________
DNR (Do Not Resuscitate) ORDER: (no, yes, location): ________________________________________________________________________
MEDICAL POWER OF ATTORNEY (who, contact info, document location): ____________________________________________________
KEY CONTACTS (relationship, name, home phone, other phone):
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
INSURANCE (company, policy type, policy ID, contact number):
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
INSTRUCTIONS: Fill this out & have ready for paramedics and ER doctors to quickly help you. Keep in your wallet/purse., glove box, Vial of Life. Keep updated.