Emergency Medical Information

 

This information will be maintained in your sealed envelope under lock and key.

It will only be unsealed and seen by Qualified Emergency Medical providers.

 (Under no circumstances will it be viewed by any club members)

 

 Name ______________________________________________________________________

 

 Address _____________________________________________________________________

 

 Birth date_________ Sex ________ Ht ________ Wt________ Hair color________ Eye Color______

 

 Emergency contact __________________________ Relationship _______________Phone ___________

 

Any signed living will/organ door instructions (location of info) ______________________________________

 

Medical Problem (Circle those that apply)

 

               None                                Emphysema                                            Kidney dialysis                               Diabetes

               Deaf                                 High blood pressure                              Blood disorder                                Aneurysm

               Blind                                Low blood Pressure                               Pacemaker                                        Blood type______

               Stroke                              Epileptic seizures                                    Sickle cell trait                                 Other __________

              Heart Ailment                  One kidney                                              Cancer

                      

 Surgeries __________________________________________________________________________

 

 Allergies (Especially to medications) ________________________________________________________________________________

 

Current medications (Attach list if needed)  _________________________________________________________________________

 

Primary physician _______________________________________________Phone__________________

 

 Specialist physician ______________________________________________Phone__________________

 

 Insurance: Primary ______________________________Secondary _______________________________

                                            (Include copies of insurance card with policy numbers and phone contacts)

 

Preferred hospital________________________________ Preferred pharmacy_______________________

 

Signature ________________________________________________________Date _______________

 

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         I have, of my own volition, chosen not to supply any of the information included above and will accept all liability

          for any consequences there from.

 

Signature _________________________________________________________Date _____________