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My Emergency Card

Download My Emergency Card pdf document (22k) handout.

  • Name:
  • Date of Birth:
  • Home Phone:
  • Emergency Contacts (Name, Relationship, Phone for each):
  • Family Doctor and Phone:
  • Local Clinic/Hospital and Phone:
  • Current Medications:
  • Known Allergies:
  • Other Information:

Emergency Numbers

  • Fire Department:
  • Local Police Department:

Do you have any of the following conditions?

  • Heart Disease (Yes or No)
  • Previous Heart Attack (Yes or No)
  • High Blood Pressure (Yes or No)
  • Diabetes (Yes or No)
  • Other

Current Medications:

Known Allergies:

Other Information:

Back to Session 2

Information on this page is taken from the English print version of “Your Heart, Your Life, A Community Health Worker's Manual.” U.S. Department of Health and Human Services, National Institutes of Health, National Heart Lung and Blood Institute, NIH Publication No. 08-3674, Originally Printed 1999, Revised May 2008.

Last Updated March 2012

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