Emergency Medical Information Form - Excel by mpU36R

VIEWS: 148 PAGES: 1

									                                     Northern Chesapeake Cruising Club



     EMERGENCY MEDICAL INFORMATION FORM:
Persons Name:
Persons Birth Date:
Emergency
Contact Info
Primary Contact Name and
relationship:
Power of Attorney (yes or no)

Phone Number: H: C: W:
Secondary Contact Name
and relationship:
Power of Attorney (yes or no)
Phone Number: H: C: W:
Third Contact Name and
relationship:
Phone Number: H: C: W:
Fourth Contact Name and
relationship:
Phone Number: H: C: W:
Dr. Information
Name of Primary Care
Doctor:
Phone Number:
Name of Specialist Doctor:

Phone Number:
List of drugs & daily
doseage currently
prescribed:
Allergies:
Code Status:
Details if Limited Code:
List of medical Issues:
List of diagnoses, prior
hospitalizations w/reason,
Name of Hospital, hospital
physician contact info if
known.
Enter todays date.
It is suggested that this form be completed and stowed onboard where it can be found in case of an
emergency. A possible location is in an envelope marked Emergency Medical Info and stowed in your chart
table.




                                                06/04/2012

								
To top