English Medical History For Non-English Speakers

Multilingual Speakers Please Save Lives

Be An Angel of Healing Helper

For Non-English Speakers

 English Medical History Questionnaire

For Non-English Speakers

These Forms Can Help First Responders, EMTs, Medics & Doctors to Save Lives

English Medical History for __________________

Who Speaks Only __________________

Created by _________________________ On ______________ Tel.____________

 

Patient’s Medical Information

Make One for Each Family Member & Keep It with You for Emergencies.

Name _________________________       Phone#______________________________

Birthdate_______________________                Birthplace_____________________________

Address______________________________________________________________________

City___________________________                State__________________ Zip_______________

Emergency contact –Name _____________________________ Phone ___________________

Primary Care Physician – Name_______________________________Phone_______________

Specialist Physician – Name _______________________________        Phone _______________

Specialist Physician – Name _______________________________        Phone _______________

First Hospital Choice – __________________________________________________________

I am allergic to:________________________________________________________________

My History – Surgery or Condition

Dates                                                      Event ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Insurance Co. _________________________ Phone________________

Policy Group _________________________     ID#_______________________________

Other Important Information _____________________________________

Other English speaking Contacts – Name _____________________________#Phone  _______

Name ____________________________         Phone __________________

Based on the Writing of Rev. Mike Wanner Who Channels the Angel of Healing – Raphael