Please provide a copy of this form to Fire/EMS crews in the event of an emergency. Be sure that information is kept up to date as best as possible.

Name: ______________________________                 ____________________________________

Age:____________                                                              Date of Birth:_______________

SSN (optional):_____________________            

Medical History

I have had Heart Attacks/Other Heart issues in the past:     Yes ______  No______

I have had a stroke before: Yes______ No______

I have had Asthma Attacks/COPD/Other breathing troubles before: Yes_____ No______

I have had seizures before/ I have a known seizure disorder: Yes____ No_____

I have had issues with my blood sugar getting too high/too low/ I do have Diabetes: Yes____ No____

I am known to have allergic reactions to foods/bugs/medications: Yes____ No____

Other Medical Conditions/Past Medical concerns and surgeries______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



I'm currently prescribed the following medications _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I am compliant with ALL of my Medications: Yes_____ No______


I have a Cardiologist: Yes___ No____ Name (if yes)___________________________________________ Phone_____________

I have a Neurologist: Yes____ No____ Name (if yes) ___________________________________________ Phone ____________

I have a Primary Physician: Yes___ No___ Name (if yes) ________________________________________ Phone_____________

**Print new copies as needed on

Where Do I Place This Form?

Ideally, you will want to have this form in an easily accessible location for you or family to obtain, such as in a drawer in the bedroom, cabinet in living room or kitchen, next to or with medications that are taken daily, in a purse or daily bag used when outdoors.

In the event anyone in the home is not able to walk without difficulty (or bed bound), hang medical form on a wall inside the home near the front door, or on the refrigerator for easy access

If you or a family member has a DNR, make sure that that orange document is viewable and available in the event of cardiac arrest. without that form, responders will be required by law to begin CPR and provide all life saving efforts against the wishes of the individual. Have this form available nearby a DNR to provide responders with necessary medical history.

Make as many copies as you need of this form as you need. If you would like this form mailed to you along with envelopes with the Medical Decal on it, please send us a message on our online contact form.