Skip Navigation

Family Health Information Guide for Emergencies

May 22, 2006

Contact: HHS Press Office
(202) 690-6343

Overview: This fact sheet contains suggested health related information that could be stored electronically and sent to a trusted family member or friend for retrieval if the individual or family is displaced in a disaster.

Personal emergency preparation is a continuing process that helps develop, manage, and maintain information and resources necessary to deal with a disaster. Maintaining a record of the health history of everyone in your family is one of the best ways to have constant access to your health information over the course of a lifetime. This is especially important during an emergency when it may be difficult to locate and obtain medical records. The more you prepare before an emergency strikes, the more quickly you will recover.

The amount of information that you will need will depend on your circumstances. For example, if you are under a doctor’s care for a serious medical condition you might want to have more information available than what is described in this document. This sample form is intended for your own use as a temporary record that lists important health information needed during disasters and similar situations. This list represents key information but is not a comprehensive list. Feel free to alter this sample form to fit your needs. At the end of the document you will find more resources related to keeping track of health information.

You may want to keep your information at an alternate secure site where it can be accessed from a remote location. The solution could be as simple as sending a hard copy or an electronic copy stored on a CD-ROM to a trusted relative or friend. As with any confidential information, please be selective and take all necessary precautions to protect it from inappropriate disclosure.

You should include information for every member of the household (including spouse, children, grandparents, others).

General Information

  • Today’s Date:
  • Name:
  • Address:
  • Home Phone Number:
  • Work Phone Number
  • Cell Phone Number:
  • Email:
  • Date of Birth:
  • Drivers License Number:
  • Local Emergency Contact Name and Phone Number:
  • Out of Town Emergency Contact Name and Phone Number:
  • Name and Phone Number of Primary Care Physician:
  • Name and Phone Number of Primary Pharmacist:
  • Power of Attorney for Emergency Medical Procedures:
  • Marital Status:
  • Religious Affiliation:

Medical History

  • Allergies and Drug Sensitivities:
  • Medications Currently Taken and Dosage:
    (if you are evacuated, remember to bring your medication with you, as well as any supplies necessary to administer the medication (nebulizer, syringes, glucometer, etc.))
  • List Current Medical Conditions:
  • List Your Previous Surgeries:
  • Immunization and Vaccinations:
    (obtain a copy of the vaccinations record from your provider)

Other Important Information To Consider

You should consider keeping a record of additional information as part of your disaster preparedness, such as the Social Security Number of each member of your family, a copy of your health insurance, car insurance, and homeowner’s insurance cards, your pet's veterinarian's name and phone number, your pet’s medication, your bank account, etc.

Other Links