Emergency Contact List with Health Information
1. Personal Information:
Name: [Your Full Name]
Date of Birth: [Your Date of Birth]
Blood Type: [Your Blood Type]
History of any prior blood transfusion [where, when, how much, what specifically (whole blood, platelets, pRBCs, plasma, etc.]
Allergies: [Any Allergies]
Medical Conditions: [Any Relevant Medical Conditions]
Recent travel history: [Specify a location, dates]
2. Legal Documents:
Living Will (Advance Healthcare Directive): [Specify a location]
Power of Attorney: [Specify a location]
Healthcare Proxy (Medical Power of Attorney): [Specify location]
Organ donor status: Specify whether the person is an organ donor or not.
3. Primary Contacts:
Emergency Services: 911 (or your local emergency number)
Primary Physician: [Physician’s Name] - [Physician’s Contact Number]
Specialists if applicable: [Physician’s Name] - [Physician’s Contact Number]
Hospital of Choice: [Hospital Name] - [Hospital Contact Number]
4. Family Contacts:
Spouse/Partner: [Spouse/Partner’s Name] - [Spouse/Partner’s Contact Number]
Parent/Guardian: [Parent/Guardian’s Name] - [Parent/Guardian’s Contact Number]
Adult Children: [Name] Contact Number]
Adult Siblings; [Name] Contact Number]
5. Close Friends:
Friend 1: [Friend's Name] - [Friend's Contact Number]
Friend 2: [Friend's Name] - [Friend's Contact Number]
6. Work Contacts:
Supervisor/Manager: [Supervisor/Manager’s Name] - [Supervisor/Manager’s Contact Number]
HR Department: [HR Representative’s Name] - [HR Representative’s Contact Number]
7. Neighbors:
Neighbor 1: [Neighbor's Name] - [Neighbor's Contact Number]
Neighbor 2: [Neighbor's Name] - [Neighbor's Contact Number]
8. Additional Contacts:
Close Relative: [Relative’s Name] - [Relative’s Contact Number]
Child's School: [School Name] - [School Contact Number]
9. Health Information:
Primary healthcare provider's name and contact information
Health insurance information (policy number, provider)
Allergies (medications, foods, other substances)
Chronic medical conditions (e.g., diabetes, asthma, heart conditions)
Medications: List of current medications, dosage, and frequency
Implants or medical devices: Specify any implants or devices (e.g., pacemaker)
History of adverse reactions to medications or treatments
Prior Surgeries: [include details such as type, date, and location]
Immunization history
Recent travel history
10. Legal and Health Representatives:
Legal Representative: [Lawyer’s Name] - [Lawyer’s Contact Number]
Healthcare Representative: [Healthcare Representative’s Name] - [Healthcare Representative’s Contact Number]
11. Insurance Information:
Health Insurance Provider: [Provider’s Name] - [Insurance Contact Number]
Car Insurance Provider: [Provider’s Name] - [Insurance Contact Number]
12. Pet Information:
Pet Sitter/Veterinarian: [Name] - [Contact Number]
13. Any Additional Information:
[Any other important details or contacts]
Remember to keep this list in a visible and easily accessible place. Regularly review and update the information as needed. Share the existence of this list with close family members and friends.
