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Health Information for the Public

My Emergency Card

Your Choice for Change - Honoring the Gift of Heart Health for American Indians

Section Two - Act in Time to Heart Attack Signs!

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Basic Information

Name: __________________________
Date of Birth: __________________________
Home Phone: __________________________
Emergency Contacts:
(Name, Relationship, Phone)
__________________________

Do you have any of the following conditions?

Heart disease _____ Yes    _____ No
Previous heart attack _____ Yes    _____ No
High Blood Pressure _____ Yes    _____ No
High Blood Cholesterol _____ Yes    _____ No
Diabetes _____ Yes    _____ No
Other: __________________________

List current medications, known allergies, and any other information.

Current medications: __________________________
Known allergies: __________________________
Other information: __________________________

Emergency Numbers

Family Doctor: __________________________
Phone: __________________________
Local Clinic/Hospital: __________________________
Phone: __________________________
Fire Department: __________________________
Local Police Department: __________________________

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
National Institutes of Health
National Heart, Lung, and Blood Institute
NIH Publication No. 08-6340
June 2008

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