American Red Cross- Medical Concerns

Disaster Preparedness for People With Disabilities (Printable Page)

Appendix C: Important Lists

Emergency Information List
Please complete this form and distribute copies to your emergency contact people as well as to each member in your network.

Name:___________________________________________

Birth date:___________________________________________

Address:___________________________________________

___________________________________________

Telephone number:___________________________________________

Social Security number:___________________________________________

Local emergency contact person:___________________________________________

Emergency contact person's numbers:___________________________________________

Network members:

___________________________________________

Network member's home/work numbers:

___________________________________________

Out-of-town contact:___________________________________________

Out-of-town contact's numbers:

___________________________________________

How best to communicate with me:___________________________________________

Medical Information List
Please complete this form and distribute copies to your emergency contact people as well as to each member in your network.

Primary physician:___________________________________________

Telephone number:___________________________________________

Address:___________________________________________

___________________________________________

Hospital affiliation:___________________________________________

Address:___________________________________________

___________________________________________

Type of health insurance:___________________________________________

Policy number:___________________________________________

Blood type:___________________________________________

Allergies and sensitivities:

___________________________________________

Medications and dosages being taken:

___________________________________________

Specific medical conditions:

___________________________________________

Physical limitations:

___________________________________________

Adaptive equipment and vendors' phones:

___________________________________________

Communication difficulties:

___________________________________________

Cognitive difficulties:

___________________________________________

Disability-Related Supplies and Special Equipment List
Check items you use, and describe item type and location. Distribute copies to your emergency contact people as well as to each member in your network.

____Glasses:
____Eating utensils:
____Grooming utensils:
____Dressing devices:
____Writing devices:
____Hearing device:
____Oxygen:
Flow rate:
____Suction equipment:
____Dialysis equipment:
____Sanitary supplies:
____Urinary supplies:
____Ostomy supplies:
____Wheelchair:
Wheelchair repair kit:
Motorized:
Manual:
____Walker:
____Crutches:
____Cane(s):
____Dentures:
____Monitors:
____Other:

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