Meade  County  EMS  -  My Medical History
Name:                                                                                         Age:                        Date of Birth:                                     


Allergies to any medications, food, or bee stings:                                                                                                             

                                                                                                                                                                                       

Medical History (please include dates if possible):

Heart:                                                                                                                                                                                  

Lungs:                                                                                                                                                                                 

Diabetic:                                                                                                                                                                              

Seizure:                                                                                                                                                                               

Stroke:                                                                                                                                                                                

Cancer:                                                                                                                                                                               

Other:                                                                                                                                                                                  

                                                                                                                                                                                       
Medications (please attach separate form if more space is needed):
Name                                                     Dosage                    Name                                                     Dosage               

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Please sign and date.  Make changes as needed, or print out a new form to keep us up to date.  This form is strictly to help the
ambulance service in an emergency.  If you are in need of an ambulance, please give this form to the EMT's.
Form filled out by:                                                                         |                                                                                    
                          print                                                                 sign

Date form filled out: