This form is intended to be a voluntary and temporary record that lists medical care and other health information for people who need care during disasters and similar situations. This form can assist health care workers to learn information about past and new health concerns for people receiving help.

Patients fill out as much information on the form as they can, and staple their immunization card listing the shots they have recently received to the form.

Information recorded on the form includes:

• Name
• Home address
• Temporary address
• Previous evacuee center location(s)
• ID number/case number
• Parent/guardian/other support person
• Active diagnoses
• Alerts
• Doctor or clinic before evacuation
• Allergies
• Active medications
• Health care encounters
• Immunizations received since evacuation