Emergency Medical Information Form

Please print 2 copies of the Emergency Medical Information and fill out both forms.  That way you will have a record for yourself and one for the Emergency responders to your 911 call.  The next step is to put the RED STICKERS (available from Guemes Connects) near the entry door(s) to your home and on the fridge or kitchen cabinet where the forms will be kept.  Of course, if you change your medications or other information, please remember to update your form.
 
For your information:
When you call 911, the First Responders will be your Guemes Volunteer EMTs and Firefighters.  They are trained and equipped to assist you.  They will be followed quickly by trained Paramedics from the Anacortes Fire Department who arrive by Ferry with the Ambulance that will transport you, if necessary, to the hospital.  They are equipped to provide more advanced treatments.
 
ALL responders to 911 calls MUST have The Physician Orders for Life-Sustaining Treatment (POLST) form in hand, on scene, in order to deal with specific wishes for their patients’ life-sustaining care.   These forms are only available from your Physician.  IN WASHINGTON STATE THE FORMS MUST BE BRIGHT GREEN.

 

Download and print this: Emergency Medical Information Form  [108kb PDF]

 

 

 

EMERGENCY MEDICAL INFORMATION

Name

 

Date

 

Allergies

 

M / F

Weight

 

Age

 

Birth Date

 

 

current medications

Drug name and dosage

For what condition?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physicians

 

Name

Phone

Primary care

 

 

Specialist

 

 

Specialist

 

 

Specialist

 

 

 

KEY MEDICAL CONDITIONS, HISTORY and DEVICES including dates (i.e.:  diabetes, mastectomy, pacemaker, etc.)

 

 

 

 

 

 

 

 

NORMAL ACTIVITY LEVEL (All activities of normal living without help, walk daily, still driving, etc.)

 

 

 

 

PERSON(S) TO BE NOTIFIED IN EMERGENCY

Name

Phone

 

 

 

 

 

 

Tags: Connects
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