EMERGENCY PREP
MEDICAL INFORMA
AREDNESS FORM
TION
AND EMERGENCY
HEALTH CARE PLAN
This MEDICAL INFORMATION AND EMERGENCY HEALTH CARE PLAN is intended to
communicate pertinent medical information and how an emergency responder or other
person could assist you in case of an emergency or natural disaster. This form should be
completed in conjunction with the MEDICAL EMERGENCY WALLET CARD. You should
keep this form with a copy of your MEDICAL EMERGENCY WALLET CARD on you at all
times and keep an extra copy of both of these items in your GO BAG. You should update
this form every six months or when there is a change in your health status/condition(s).
Date of last review and
update of this form:
______/______
PERSONAL DATA
EMERGENCY CONTACT
MEDICAL/HEALTH HISTORY
INFORMATION ABOUT MY MEDICAL EQUIPMENT AND DEVICES
(continued on back)
Name:
Date of Birth:
Phone Number:
Address:
Name:
Phone Number:
Relationship:
(Check all that apply)
mAllergies
m Arthritis
m Asthma
m Bladder/bowel issues
m Cancer
m Diabetes
m Dizziness
m Easy bleeding/bruising
m Fevers
mFainting/periods of unconsciousness
m Hearing loss
m Heart disease
mHeartburn/acidreux
m High blood pressure
m High cholesterol
m Kidney disease
m Lung disease
m Migraines
mMuscle aches
m Rash
m Seizures
m Shortness of breath
m Stomach problems
m Urinary issues
m Visual impairment
m Other (specify):
List any medical conditions that you are currently treating or have been treated for in the past (stroke, heart attack, etc.):
See my MEDICAL EMERGENCY WALLET CARD for the following information: doctor’s name, phone number, and preferred hospital;
list of allergies; and list of medications.
(Examples: pacemaker, insulin pump, ventilator, CPAP, oxygen, baclofen pump, vagal nerve stimulator, prosthetics, assistive technology)
Device type:
Doctor:
Directions for use:
Device type:
Doctor:
Directions for use:
Device type:
Doctor:
Directions for use:
This Medical Information form is part of Wisconsin Council on Physical Disabilities Be Prepared, Have a Plan: Emergency Preparedness Toolkit, made possible by the
FEMA 2012 Community Resilience Innovation Challenge grant, CDC, and by the Wisconsin Division of Public Health Emergency Preparedness (PHEP) program.
EMERGENCY PREP
MEDICAL INFORMA
AREDNESS FORM
TION
AND EMERGENCY
HEALTH CARE PLAN
DAILY LIVING AND MOBILITY SKILLS
Level of independence (check one):
m Independent: I can complete all daily living activities on my own.
m Stand-by assistance: I need assistance related to mobility tasks
and some daily living activities.
m Partial assistance: I need assistance with some daily living
activities.
m Total assistance: I need assistance with all daily living activities.
Mobility (check one):
m Ambulatory m Bed-ridden
m Wheelchair or scooter m Completely immobile
Sensory Impairments (check all that apply):
m Vision m Speech
m Hearing m Cognitive
Communication (check all that apply):
m I can communicate using my voice (words).
m I can communicate using sign language.
m I can communicate using a communication board.
m I can read lips.
m I need an interpreter for (specify language):
m I use a hearing aid and/or hearing loop.
m I use a tablet or iPad.
m I use a switch device for communication.
Other important issues, comments, or instructions:
PREFERENCES AND CONSIDERATIONS
Preferred method of transport in non-emergency situations: Possible method(s) of transport in an emergency:
Special training needed for working with me: (e.g. “I have a ventilator
and need a person trained to maintain a ventilator.”)
Special instructions for rst responders and caregivers: (e.g. triggers,
signs/symptoms, interventions)
Considerations if I fail to respond to medical treatment:
(e.g. “Consider medications I have prescribed for ‘as needed’
situations.”)
Considerations regarding my personal preferences: (e.g. “My body
temperature runs lower, so please keep a blanket and hat on me at all
times.”)
