Medical Information Printout

In a medical emergency, it can be hard to remember all the information you need - things such as allergies, insurance numbers, etc. So it's a good idea to have all the information in one place.

Our HEALTH INFORMATION FORM can help.

Simply click on the link for the form. You can fill out this form online and either save it or print it. To save, click the "Save" icon, name the form, and save to either your computer hard drive, other storage device. To print, use the "Print" button. The information you enter will NOT be saved anywhere else once the window is closed. This is to protect your privacy. When you're done, simply close the form window and continue using our site.

The form contains important information that you or the people with you will need to provide, if you are injured or have to be hospitalized. The information includes:

• your date of birth
• insurance policy numbers
• contact names and phone numbers

There is also a place to indicate any physical problems you may have, such as:

• heart disease (Read about "Coronary Heart Disease")
• diabetes (Read about "Diabetes")
• lung conditions (Read about "Respiratory System")
• cancer (Read about "Cancer: What It Is")
• stroke (Read about "Stroke")
• HIV (Read about "HIV / AIDS")

You should also fill in information on any medications you are taking, including:

• the name of the medication
• the dosage you take
• where the medicine is stored

In addition, you should list any allergies (Read about "Allergies") you have, along with any other information you think would be helpful in an emergency.

Make sure you keep the form(s) updated and stored in a convenient, safe place. Then if you need this kind of information, for example, if you need to go to the hospital or doctor's office, it's readily accessible.