Emergency Care Plan

Essential identity, contacts, healthcare information, and safety needs.

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Person receiving care

Full legal namePreferred nameDate of birthHome address

Emergency contacts

Name	Relationship	Phone	Call order

Healthcare contacts

Primary doctor / clinicPhonePharmacyPharmacy phonePreferred hospitalInsurance / member ID

Conditions and allergies

Major diagnoses or health conditionsMedicine, food, or other allergies and reactions

Communication, senses, and mobility

Best way to communicate or assist safely

Emergency Care Plan

Medicines, daily needs, legal documents, and information for a substitute caregiver.

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Medicines and treatment

Where the current medicine list is keptPerson who manages medicinesTime last scheduled medicines were givenMedical equipment used at home

Time-critical medicines or treatments

Attach the current medication list. Include prescriptions, nonprescription medicines, vitamins, supplements, inhalers, creams, injections, and past reactions.

Daily care needs

Instructions, routines, triggers, and what helps

Usual baseline and recent changes

Usual alertness, communication, walking, eating, and behaviorRecent illness, fall, hospital stay, medicine change, or new symptom

Decision-making and documents

Healthcare decision-maker / proxyPhoneAdvance directive locationPOLST / MOLST / portable medical order location, if applicable

Only an authentic, current legal or medical-order document should be used to communicate treatment limits. Do not infer wishes from this worksheet.

Backup caregiver

NamePhone

Call 911 for trouble breathing, chest pain, stroke signs, loss of consciousness, severe bleeding, serious injury, or suspected overdose. Bring both pages, the current medicine list, insurance card, identification, and any applicable advance-directive or portable medical-order document.