MEDICAL EMERGENCY INFORMATION
Please place this card on the outside of your refrigerator
Name:__________________________________________________________________________________
Your Date of Birth:____________________________________________________________________
What date you completed this form: ________________________________________________
Physician's Name & Phone Number:
1.___________________________________________________
2.___________________________________________________
3. __________________________________________________
Emergency Contact Names and Phone Numbers:
1.___________________________________________________
2.___________________________________________________
3.___________________________________________________
Medication Dose Frequency
Location Advance Directives (if applicable)
DNR & POLST require additional forms. Check which form(s)
you have.
DNR - Do Not Resuscitate
POLST - Physician Orders for Life Sustaining Treatment
Please staple a copy of these forms to this sheet, or list here
where these forms can be found in your home:
Please list any significant surgeries that you have had:
_____________________________________________________
_____________________________________________________
_____________________________________________________
Medical Conditions:
None
Asthma/COPD
Bleeding
Disorder
Diabetes/Insulin
Dependant
Heart Problems
Hypertension
Stroke
Seizures
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Alergies and Drug
Reactions:
None Known
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Please list any other information that
we should know about your medical
history or conditions:
Hospital Preference:
Forest Grove Fire & Rescue 1919 Ash Street Forest Grove, Oregon 97116 503-992-3240
Cornelius Fire Department 1311 N. Barlow Street Cornelius, Oregon 97113 503-357-3840
