Archived Family Emergency Health Information Sheet
For readers interested in the PDF version, the document is available for downloading or viewing:
Family Emergency Health Information Sheet (PDF document - 61 KB - 2 pages)
During a flu pandemic or other health emergency, you may be required to provide specific health information about yourself and others in your care to those offering health care services. This information is essential to health care providers when considering how best to treat you and your family. Using the chart below, fill in as much information as possible for each family member.
| Member 1 | Member 2 | Member 3 | Member 4 | Member 5 | Member 6 | |
|---|---|---|---|---|---|---|
| Name | ||||||
| Date of Birth | ||||||
| Provincial Health Card Number | ||||||
| Blood Type | ||||||
| Allergies | ||||||
| Existing Medical Conditions | ||||||
| Medications (include dosage) |
||||||
| Name and Contact Information for Current Health Care Provider(s) |
List of contacts
- Emergency contact
In the event you or your family members become ill, you may wish to have a relative or friend notified of the situation. They may be able to offer additional information to the health care providers treating you or may be able to help with your care. - Name:
- Telephone Number:
Relationship to you (or your family):
- Telephone Number:
- Hospitals
- Name of Hospital:
Telephone Number:
- Name of Hospital:
- Pharmacy
- Name of Pharmacy:
Telephone Number:
- Name of Pharmacy:
- Public Health Hotline
- Telephone Number:
If you and/or a family member are ill, you may need others to notify your place of work or any schools your children attend. In addition, during a pandemic, you may need to check periodically to determine if these facilities have closed their operations.
- Work
- Name of Contact:
Telephone Number:
- Name of Contact:
- Schools
- Name of School:
Telephone Number:
- Name of School: