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QualityTool

Keep It With You: Personal Medical Information Form


Description

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
Links to the Tool:
This tool is available at: http://emergency.cdc.gov/disasters/pdf/kiwy.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Developer

Centers for Disease Control and Prevention

Funding Sources

Centers for Disease Control and Prevention


QualityTool Topic

asp:qt-topic-replace-me


History

  • Release Date: 09/2005
  • Original Summary: 10/2005
Disclaimer: The inclusion of a tool in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality or Westat of the tool or of the submitter or developer of the tool. Read more.

Last updated: June 06, 2012.