Emergency
Emergency Snapshot
Blank — fill in by hand
Patient
Full name
Date of birth
Phone
Home address
Emergency contacts — call in this order
| Name | Relationship | Phone |
|---|---|---|
Allergies
| Allergy | Severity | Reaction |
|---|---|---|
Current medications
| Medication | Dose | When taken |
|---|---|---|
Conditions, implants, recent surgeries
| Condition | Notes |
|---|---|
Physician, pharmacy, insurance
Primary physician / phone
Preferred pharmacy / phone
Insurance carrier, plan, member ID
Advance directive and power of attorney
Record that they exist and where the originals are kept — do not attach the originals.
Advance directive — where kept / who has a copy
Power of attorney — where kept / who has a copy