Emergency card template for allergies

Instructions for filling out the card:

(1-11) Self-explanatory:
Name, address, phone: home, work, fax birth date, blood type, social security number, primary physician(s), insurance carrier, local and out of town emergency contacts and personal support network.

(12) Conditions, which a rescuer might need to know about (if you are not sure, list it): i.e. diabetes, epilepsy, heart condition, high blood pressure, and respiratory condition, HIV positive.

• "My disability, which is due to a head injury, sometimes makes me appear drunk. I'm not!"
• "I have a psychiatric disability, in an emergency I may become confused. Help me find a quiet corner and I should be fine in about 10 minutes; if not give me one green pill, (name of medication) located in my (purse, wallet, pocket, etc.)"
• "I take Lithium and my blood level needs to be checked every ______."
• Multiple chemical sensitivities - these conditions may not be commonly understood therefore explanations may need to be detailed. "I react to. my reaction is. do this. "

(13) Medications
If you take medication that cannot be interrupted without serious consequences, make sure this is stated clearly and include:

• Prescriptions
• Dosage
• Times taken
• Other details regarding specifications of administration/regime; i.e., insulin, etc.
• Instructions: i.e.: take my gamma globulin from the freezer; take my insulin from the refrigerator.
  Name, address, phone and fax numbers of pharmacy where you get your prescriptions filled.

(14) Anticipated assistance needed.

• "I need specific help with: walking, eating, standing, dressing, transferring."
• Walking - "best way to assist is to allow me to hang on your arm for balance."

(15) Allergies and sensitivities:
History of skin or other reaction of sickness following injection or oral administration of:

• Penicillin or other antibiotics
• Tetanus, antitoxin or other serums
• Morphine, Codeine, Demerol or other narcotics
• Adhesive tape
• Novocain or other anesthetics
• Iodine or methiolate
• Aspirin, emperin or other pain remedies
• Foods such as eggs, milk chocolate, or others
• Sulfa drugs
• Sun exposure
• Insect bites, bee stings

(16) Immunization Dates (self-explanatory)

(17a) Communication or a speech-related disability:
Specific communication needs (examples):

• "I speak using an artificial larynx, if it is not available I can write notes to communicate."
• "I may not make sense for a while if under stress, let me alone for 10 - 15 minutes and my mind should clear."
• 'I speak slowly, softly and my speech is not clear. Find a quiet place for us to communicate. Be patient! Ask me to repeat or spell out what I am saying, if you cannot understand me!"
• "I use a word board, augmentative communication device, artificial larynx, etc., to communicate. In an emergency I can point to words and letters."
• "I cannot read. I communicate using an augmentative communication device. I can point to simple pictures or key words which you will find in my wallet or emergency supply kit"
• "I may have some difficulty understanding what you are telling me, please speak slowly and use simple language."
• "My primary language is ASL (American Sign Language). I am deaf and not fluent in English, I will need an ASL interpreter. I read only very simple English."

(17b) Equipment used:

• Motorized wheelchair
• Suction machine
• Home dialysis
• Respirator
• Instructions : take my oxygen tank, take my wheelchair.

(17c) Sanitary needs:

• Indwelling catheter
• Trash

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