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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: __-__-____
Address
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: ____________________________
Medications
____________________________
____________________________
____________________________

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:
____________________________
Relation:____________________________
Phone Number: __________ Cell Phone: __________
Patient Dr's Name____________________________
Hospital____________________________ 

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CFN - California Fire News 2013 
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****REMINDER**** Every fire has the ability to be catastrophic. The wildland fire management environment has profoundly changed. Growing numbers of communities, across the nation, are experiencing longer fire seasons; more frequent, bigger, and more severe, fires are a real threat. Be careful with all campfires and equipment.
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