Thursday, March 28, 2013

Printable EMS Information Sheet Post on Refrigerator

Emergency Medical Treatment Information Sheet 
(Post on Refrigerator)

Patient Information
Patient Name ( First, M.I. Last)___________________________________
Age: ___
Date of Birth: __-__-____
City: ___________
Zip Code _________
Phone Number: __________

Insurance Information (Select One or Multiple)
Primary Medical Insurance Name: ____________________________
Primary Insurance Number #___________________________
Secondary Medical Insurance Name: ____________________________
Secondary Insurance Number #___________________________
Medi‐Care #___________________________
Patient Medical History (Check All That Apply)
Cardiac ☐ - Stroke ☐ - Diabetes ☐ - Seizures ☐ - High B/P - ☐ Cancer ☐ - Psych ☐ - Dementia ☐ - Asthma ☐ - COPD ☐ - Dialysis ☐ - Other ☐
Other: ____________________________

Known Allergies To Medications? Yes ☐ No ☐
List Medication Allergies

Hospital Preference For Transport: ( Select 1st, 2nd, 3rd Choices )
1.) ____________________________
2.) ____________________________
3.) ____________________________

Family Member To Be Notified:
Phone Number: __________ Cell Phone: __________
Patient Dr's Name____________________________


CFN - California Fire News 2013 

1 comment:

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