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:

Other person(s) to be notified in an Emergency:

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.