Date Completed:
First Name Middle Initial Last Name Last 4 of SSN
Address City State Zip Telephone #
Date of Birth Male/Female Height
Weight Blood type Religion
Hearing Difficulties
(Check if yes)
Vision Difficulties
(Check if yes)
(Check if yes)
Unable to Speak?
(Check if yes)
Primary Language
Medical Conditions
(Check if yes)
Heart Disease/Heart attack Diabetes High Blood Pressure Asthma/COPD Stroke CHF
Kidney Disease/Dialysis Coronary Artery Disease Opioid Use Other (Please List):
Current Medications
(Dosage & Times a Day)
Doctors Name and Phone Number (Primary Care preferred)
Special Instructions (MOLST, DNR, etc.)
Health Insurance Policy
Emergency Contact(s) – (Name, Phone Number, & Relationship)
Medical Information Form
Dear Citizen of Annapolis,
The Annapolis Fire Department invites you to use the Life-in-a-Bag Program. The
Life-in-a-Bag Program will give First Responders all the medical information they need
to treat you most appropriately. The Life-in-a-Bag Program is designed to speak for
you when you cannot speak for yourself. The Medical Information Form contains
important medical information that can assist Emergency Medical Services providers
to care for you if you are unable to speak for yourself. There are 4 simple steps to
getting your Life-in-a-Bag kit ready:
If you do not want to display the sticker on your front door, place just the baggie
on your refrigerator door.
You can print your Life-in-a-Bag form Online at:
For more information, please contact: EMS35@ANNAPOLIS.GOV
To receive voicemails, text messages, and e-mails in case of
emergencies and other events, sign up for
Alert Annapolis
For Emergency notifications download the Free
Prepare Me Annapolis App
Available in the Apple Store and Google Play Store!