MEDICAL EMERGENCY INFORMATION - A Simple Card
Name_______________________ Age__________ Weight_________
Address_________________________________ Tel # ( )__________
City____________________State_________ Zip__________________
Emergency Call:___________________________ Tel# ( )__________
(Optional) Social Security No.___________________________
Doctor:____________________( )_____________ Religion_________
Diagnoses:_______________________________ Blood Pressure /
Blood Type:______________ALLERGIES________________________
Drugs:__________________ _________________ Pen_____Sulfa____
_____________________ ____________________
Current Therapy______________________________________________
___________________________________________________________
EKG:________________________Chest x-ray:
Legal: Living Will Yes_________ No _________
Designated Person for Durable Power of Attorney____________________
Resuscitation: (Code Status) Full code: Yes_________ No ________
Chest compression Yes___________ No___________
Chemical code Yes___________ No___________
Pharmaco(drug) therapy Yes___________ No___________
No code (DNR) Yes___________ No___________
Organ Donor: Cornea Yes_________ No__________
Body Organs Yes__________ No___________
 
Witness#1_______________#2_______________ Date_____________________
Signature#1_____________#2________________ Date_____________________