EMERGENCY HEALTH INFORMATION & SPECIAL MEDICAL INSTRUCTIONS 

Name: _________________________________Birth date: (MM/DD/YY) ___________

Address: _______________________________Gender: _____ Blood Type:_________ 

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Home Phone: (____)____________ Primary Insurance:_________________________

Other Phone: (____)____________ Secondary Insurance: _______________________

Email: _________________________ Religious Preference: _____________________

Advanced Directives: Yes ___ No ___ Document Location: _______________________

Health Care Power Of Attorney:  __________________ Doc. Location: _____________ 

EMERGENCY CONTACTS:

Out-of-State: _____________________________________  Phone (___)___________

Local: ______________________  Relationship _________  Phone (___)___________

Local:_______________________ Relationship _________  Phone (___)___________

Relative: _________________________________________ Phone (___)___________

Physician (Primary):________________________________ Phone (___)___________

Specialty Physician: ________________________________ Phone (___)___________

Special Medical Condition:_________________________________________________

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Medical Apparatus: (oxygen, walker, etc.)_____________________________________

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Other Current Medical Conditions:___________________________________________

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Vaccinations: (Yr) Tetanus: _____ Pneumonia: ______  Flu: _______ Other: _________

Allergies                                                       Reaction

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Current Medications

Drug Name       Dosage (mg)     Time/Frequency      What For       Description (color, #)                                                                                                                                                                                                                                                                                          _______________________________________________________________________

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