| Emergency Medical Record Form |
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When you create your E-mergency account you -
and all members of your account - will be assigned
your own private and secure Emergency Medical Record
(EMR) site where you enter your medical information.
We recommend that you fill in your
information with your doctor, so that you include all
pertinent information about allergies, medical or health
conditions, important medical procedures such as surgeries,
medical devices, and all medications that you take.
Because E-mergency was developed in partnership with first responders,
the categories that we prompt you to enter contain Primary Assessment
information that helps EMS workers make the right treatment choices
and avoid potential medical errors in the first crucial minutes.
So it's important to be thorough.
The purpose of this page is to provide an example
of what a filled-out form might look like.
This form is not intended to resemble any real person,
but to show how filled-in fields appear - and how this
information will appear on your phone.
Any resemblance to the health profile of any individual
is purely coincidental.
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| Vitals |
| Sex |
 |
| Age |
56 |
| Height |
70" / 177cm |
| Weight |
189lbs / 85.9kg |
| Blood Type |
B- |
| Normal Blood Pressure |
135 / 90 |
| Normal Heart Rate |
70 |
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| Vitals describes the basic physical information that EMTs need. |
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| Normal blood pressure and normal heart rate are important. Athletes, for instance, may have normally "low" heart rates. |
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| Warnings |
| EMS Alert |
Hepatitus - B |
| Medical Alert |
Addisons |
| Medications |
Hydrocortisone |
| Medication Allergies |
Penicillan, Latex |
| Other Allergies |
Bee Sting |
| Directives |
No CPR |
| Document Location |
Glovebox, fridge |
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| Contagious disease warning |
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| Disease that may affect immediate treatment. Associated medication alert. |
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| Warnings describes diseases, allergies, medical test results that EMTs need to know immediately to treat you appropriately & avoid harm. |
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| History |
| Medical Condition |
Hypertension |
| Medical Procedures |
Gall bladder
removed, 9/08 |
| Test Results |
ECG: A-fib |
| Medical devices |
Defibrillator (ICD) |
| Family History |
Father cardiac |
| Smoking Yrs / Amt |
23 / .5 pack |
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| History describes chronic medical conditions, associated medications, any medical procedures or devices. |
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| Important Test Results |
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| Parental heart history (or other pertinent, genetic history) and personal habits that affect health are important. |
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I like knowing that all of our
medical information is in in one
place in case something happens.
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- EMT approved for ease of use, speed & thorough information.
- Auto-notifies your contacts of incident time, GPS location and medical facility.
- Easily installed & updatable phone app plus website in case of broken (or no) phone.
- The fastest way to get your vital medical information in front of a First Responder.
- Just $8.95 for your Account + 95¢ for additional Members
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"Carry the card with the heart to let us know that your emergency medical information is just a
click away." |
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Emergency Medical Record View
If you do not have an Android or iPhone, EMTs can access your EMR View Site on your Internet-enabled phone.
If you have a non-Internet phone, or your phone is broken or lost,
EMTs will follow the instructions on your card to access your
EMR site on their own phones or on their laptops.
Android, iPhone, iPod Touch, Internet-enabled phone,
or no phone - with E-mergency you're protected.
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