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Health Library : Non-Traumatic Emergencies


Emergency Information Form

In an emergency, it is easy to "forget" even the most well-known information. That is why it is crucial for you to complete the information in this form for each member of your household. Then, distribute copies to each member of your household. Also, post all copies by each telephone and in easy to find places in your home, automobile, or place of business. Be sure to update the information frequently.

Also, make copies for non-resident relatives, babysitters, caretakers, neighbors, teachers - anyone who has contact with you or who is periodically responsible for your children (or any disabled or elderly persons in your home).

If you own a cell phone, put 2 different contacts in your phone under ICE for "in case of emergency," so emergency room staff can call your contacts in the event you cannot communicate. Examples could be ICE -mom, or ICE-husband to identify your contact.

Emergency Telephone Numbers:

9 1 1 (nine, one, one)

Emergency Transport System
(if 9-1-1 system is not available in your area)


Post the poison center telephone number by every telephone in your home. The national, toll-free poison control center locator number is: 800-222-1222. From here, you will be automatically redirected to the nearest Poison Center in your area.

Poison control
Physician's name/telephone
Hospital emergency room

This information is

Person's Full Name
Date of birth
Heightat last physical in:
Weightat last physical in:
Home Address
Directions to Home
Home Telephone
Medical Conditions
Current Medications

Emergency Contacts:

Contact Person #1
Work or Home Address
Contact Person #2
Work or Home Address
Contact Person #3
Work or Home Address

Additional Instructions:

Click here to view the
Online Resources of Non-Traumatic Emergencies

 Sources & References




 Tests & Procedures:

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