Personal Information Sheet

July 14, 2011 The Provident Princess 0 Comments

There is a city in my state that has instituted the Vial of Life program with the mission of making their citizens and city more disaster resilient. One of the free resources offered is a personal information sheet you can fill out that lists personal info, emergency contacts, medical information and history as well as medications currently being taken along with the reasons and dosages needed.

I think this sheet would be great for everyone to fill out and its nice that you only have to fill in the blanks instead of coming up with all the information yourself. This would be useful to stick in your disaster supplies grab bag or even have at home particularly for those who are homebound, living alone, or with special medical needs, in a place where it can be easily located by 911 responders in the event of an emergency. having this information available could help save your life.

You can print the sheet here.

Tips for completing the personal information sheet:
The back of the sheet can be used when extra space is needed to complete any section.  Place an
asterisk (*) in the appropriate section to draw attention to the back of the sheet.

Personal Information:
Complete as thoroughly as possible.
If more space is needed, place an asterisk (*) in the section to refer the reader to the back of the form.
Medical History:
Check off any medical conditions you have or may have had.  If you would like to provide specifi c
information on a condition, use an asterisk (*) instead of a check mark, then elaborate in the “Other
Medical Problems...” section, or on the backside of the form.
If you have suffered a stroke, “related defi cit” refers to any impairment now suffered as a result (for
example, weakness on left side).
Also list any allergies to medications or check “none” if there are no known allergies.
Medications Taken:
Note the location where medications are stored (for example, bathroom medicine cabinet).
List all prescription and non-prescription drugs currently being taken.
As an alternative to handwriting this section, call your pharmacist or physician for a printout of current
medications and attach the printout to the information sheet.
REMEMBER, update this section as prescriptions change!
Other Emergency Information / Instructions:
Use this section to record any other pertinent information which might be useful to 911 responders.

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