“COOL AID” PROGRAM

Name:

Address:

Phone Number:

Doctor:

Phone Number:

Emergency Contact:

Phone Number:

Health Card Number:

Date of Birth: / /

Medical History: (place a check mark beside all that applies)

Heart Attack (date of last)

Angina

Congestive Heart Failure

Asthma

Bronchitis

Stroke

High Blood Pressure

Diabetes

Seizures

Other (please specify)

Pace Maker

Emphysema

Implanted Defibrillator

Bleeding (ulcers)

Osteoporosis

Current Medication and Dosage: (prescribed)

Once you have completed recording your medical history, place this report on the front of your refrigerator with a magnet.

Paramedics will need this information if you are unable to communicate at the time of the emergency.