Patient - Personal data and important information:

NB ▢ | Ms ▢ | Mr ▢

Nationality :

Name :

Mother tongue :

First name :

Religion :

Born on :

Health insurance :

Street/No. :

Vers. no. :

PLZ/Place :

Blood group :

Allergies and intolerances to medication and food:

General practitioner :

Private care / care service :

Name :

Name :

Address :

Address :

Landline phone :

Landline phone :

Mobile phone :

Mobile phone :

Email :

Email :

If necessary, I prefer the following hospital :

Storage locations :

Medication :

Medication :

▢ Asthma

▢ Epilepsy

Emergency kit :

▢ MS

▢ Heart

Living will :

▢ Diabetes

▢ Blood pressure

Organ donor card :        

▢ Dementia

▢ Parkinson's disease

Vaccination certificate :

▢ Stroke

▢

▢ _________________ : _______________________________

▢

▢

Do you have any illnesses/therapies that could have an impact on emergency treatment?

▢ Yes | ▢ No

Heart attack

If yes, when?

▢ Yes | ▢ No

Pacemaker

If yes, when?

▢ Yes | ▢ No

Bypass operation

If yes, when?

▢ Yes | ▢ No

Stroke

If yes, when?

▢ Yes | ▢ No

Kidney disease / dialysis

If yes, since?

▢ Yes | ▢ No

High blood pressure (hypertension)

Values :

▢ Yes | ▢ No

Low blood pressure (hypotension)

Values :

▢ Yes | ▢ No

Rapid pulse (tachycardia)

Values :

▢ Yes | ▢ No

Slow pulse (bradycardia)

Values :

▢ Yes | ▢ No

Diabetes

Typo?

▢ Yes | ▢ No

Seizure disorders / epilepsy

Which one?

Important surgical procedures (implants etc.) :

Further important information / diagnoses :  

What medication do you take daily? Preparation / dose / quantity / since when (date) :

(Please enclose current medication plan!)

Emergency contact person 1 :

Emergency contact person 2 :

Relationship :

Relationship :

Name :

Name :

Address :

Address :

Landline phone :

Landline phone :

Mobile phone :

Mobile phone :

Email :

Email :

The following person relies on my daily contact and needs care or is picked up from daycare/school or institution:

Relationship :

Landline phone :

Name :

Mobile phone :

Address :

Email :

Do you have a pet? ▢ Yes | ▢ No

If Yes Number :

Pet names :

Are there any special features that need to be considered when caring for the pet?

Who can take care of the pet in an emergency?

Name :

Email :

Landline phone :

Mobile phone :

Further important notes :

Who has completed this emergency information sheet?

All information is correct and has been completed by me or a person designated by me. I confirm that I have provided all information to the best of my knowledge.

Furthermore, I understand that I am responsible for ensuring that I keep all details and information up to date.

The use of the emergency information sheet and the information provided therein is the sole responsibility of the signatory!

Name of the signatory :

Relationship : ▢ Self | ▢

Place , Date :

Signature :

__________________________________________