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Directions for preparing and maintaining an Emergency Medical Information Record


GENERAL INFORMATION

Directions for preparing and maintaining an Emergency Medical Information Record.

  1. Complete all applicable items on the Emergency Medical Information document, preparing an individual copy (file) for each member of the household.

  2. Create a “water proof tube” made of 2” diameter x 11 ¾” length, Schedule #125 white PVC pipe with two (2) 2” flat PVC end caps (These materials can be secured from any irrigation or hardware supplier). Paint the two end caps RED and use a black marker to print (in large letters) EMERGENCY MEDICAL INFORMATION on the white surface of the PVC tube (label stock can also be used).

  3. Place all documents pertaining to each individual of the household (with attachments) in an individual 8 ½” x 11” plastic sheet protector (Avery #PV119 or similar). Place the completed document in the “waterproof tube” for safety and store the tube in the kitchen refrigerator door storage area with the RED end caps installed. (It is possible that more than one (1) tube may be required, depending upon the family size.)

  4. Instruct all family members, custodians, care givers, children or house sitters and any other assistance personnel who will be in the home, that an EMERGENCY MEDICAL INFORMATION (EMI) tube is stored in the kitchen refrigerator door storage area. In case of an emergency the EMI tube is to be made available to the Emergency Medical Service personnel -- fire, emergency aid -- when they arrive at the home. Notify the Emergency Medical Service personnel that EMERGENCY MEDICAL INFORMATION on the patient is located in the kitchen refrigerator door storage area.

  5. Emergency Medical Service personnel will retrieve the appropriate file from the tube to assist in your medical care. They may take the individual file to the hospital to assist in the patient care.

  6. When the patient leaves the hospital, arrange for pick-up of the individual EMI file. Return file to its storage location within the refrigerator storage area EMI tube.

  7. Update your file on a regular basis to reflect current medical treatment, at least once a year, more often if necessary. It would also be advisable to maintain a copy in a safety deposit box or other safe place, in case the original was lost.

  8. An information card should be prepared and attached to each vehicle registration, listing family members, address and telephone number (home and office). Also identify on the “card” that emergency medical information for each member of the family is maintained and retrievable from the EMI tube which is stored in the residence kitchen refrigerator.

EMERGENCY MEDICAL INFORMATION

Either fill in or circle the correct response.

  1. Patient: Sex: M F SS#

First Initial Last

  1. Address:

Street (Apt.) City State Zip

  1. Telephone: Home#: Work#:

Cell#: Cell#:

  1. Date of Birth: Place: Religion:

day/month/year

  1. Blood Type: Bleeding Problems:

  1. Medical Aids: Pacemaker yes no Model#

Heart Valve yes no Name/Type

Implants yes no Name/Type

Hearing Aids yes no # Type

Dentures yes no Upper Lower

Oxygen yes no

Others (identify):

  1. List Surgeries or Hospitalizations within last five (5) years:

Surgery Date

Surgery Date

Surgery Date

Copy Attached #7? yes no

8. Childhood diseases:

Mumps Measles Chicken Pox

9. List Vaccinations: Type: Date:

List Allergies (if any):

List Medications Allergic To (if any):

Copy Attached #9? yes no

10. Identify location of all medications (either prescription or over-the-counter) in the HOME.

11. List all MEDICAL PROBLEMS currently treated for:

Copy Attached #11? yes no

12. List all current physician-prescribed prescriptions and over-the-counter medications:

Brand/Generic Name Schedule of Use

Type (pill, capsule, liquid, injection) Dosage

Copy Attached #12? yes no

(Recommend that a copy of medication information provided also be retained for each individual billfold.)

13. Spouse: Living? yes no

First Initial//Maiden Last

Telephone: Home#: Work#:

Cell: Home#: Work#:

14. Companion: Living? yes no

First Initial/Maiden Last

Telephone: Home#: Work#:

Cell: Home#: Work#:

15. List other emergency contacts:

Name Address

Telephone: Home#: Work#:

Cell: Home#: Work#:

Copy Attached #15? yes no

16. Primary Physician: Phone:

First Initial Last

17. Ophthalmologist: Phone:

First Initial Last

18. Dentist: Phone:

First Initial Last

19. Specialists: Phone:

First Initial Last

20. Preferred Hospital: 1st 2nd

21. Medical Insurance (private): yes no If yes, policy#:

Name of Insurance Company:

Copy of Medical Insurance Card Attached #21? yes no

22. Medicare: yes no If yes, policy#:

Copy of Medical Insurance Card Attached #22? yes no

23. Medicaid: yes no If yes, policy#:

Copy of Medical Insurance Card Attached #23? yes no

24. Military Identification Card (if applicable) Active Retired

Copy of Military ID Card Attached #24? yes no

(Medical Insurance and Military ID Cards can all be photocopied onto one sheet)

25. Parents: Father Living? yes no

First Initial Last

Mother Living? yes no

First Maiden Last

26. Adopted: yes no

If yes provide as much information on your parents’ health that you know:

Copy Attached #26? yes no

27. Marital Status: single married divorced separated

widow widower significant other

28. I (have) (have not) COMPLETED a Durable Power of Attorney.

Copy Attached #28? yes no

Copy has been provided to Primary Physician? yes no

Location of Original Document?

29. I (have) (have not) COMPLETED a Directive to Physicians (living will).

Copy Attached #29? yes no

Copy has been provided to Primary Physician? yes no

Location of Original Document?

30. Organ/Tissue Donor: yes no

If YES, I have discussed donation with my family members? yes no

Signature of Donor: Date:

PREPARED (DATE) UPDATED (DATE)

Facilitator: Hambelton, Yakima, 2001