College Student’s Emergency Information Sheet

Post the following information on a bulletin board, by the phone or another handy place in your dorm room/apartment. Make sure your roommates know about this sheet and its location in case of an emergency. (Download the pdf version of our College Emergency Contact & Information.)

Download the free My Personal Medication Record pdf from the AARP  in English or Spanish. Also, along with your medical history, print out our Medical Appointment Tracking Form to take to each doctor or medical appointment. After each appointment, add all medical notes to your personal medical folder.

WHN TIP – Go Digital: Save your medical history and contact information to a flash drive or the cloud where it can be easily accessed.

College Emergency Contact & Information Sheet

Your Name________________________________________

Address_____________________________________________________

Phone Number________________________________________________

Date of Birth__________________________________________________

Social Security Number___________________________________________

Emergency Contact (home/work phone and relationship)_______________________________________________

Emergency Contact (home/work phone and relationship)_______________________________________________

Health Insurance Information

Company___________________________________________________

Phone_____________________________________________________

Policy Holder’s Name___________________________________________

Policy Number________________________________________________

Your Medical History (date and nature of illnesses, surgeries)

Illness and Date________________________________________________

Illness and Date________________________________________________

Illness and Date________________________________________________

Illness and Date________________________________________________

Allergies_____________________________________________________

Health Conditions______________________________________________

Current Medications_____________________________________________

____________________________________________________________

____________________________________________________________

Vaccinations

Talk to your school’s health services about health requirements. Not all listed vaccinations are required or necessary to have more than once. Also, if you plan to travel abroad during college you may need extra vaccinations and/or documentation of vaccinations.

Type                                                     Date #1      Date #2          Date #3          Date #4

Chickenpox (Varicella)                   ______________________________________________

DTP                                                    ______________________________________________
(Diphtheria, Tetanus, Pertussis)

Hepatitis A                                       ______________________________________________

Hepatitis B                                       ______________________________________________

Influenza                                          ______________________________________________

Meningococcus                               ______________________________________________

MMR                                                 ______________________________________________
(Measles, Mumps, Rubella)

Polio                                                  ______________________________________________

Rabies                                               ______________________________________________

Tetanus                                             ______________________________________________

Other                                                 ______________________________________________

Other                                                 ______________________________________________

Tuberculosis (test)

Date:                  Results:

__________________________________________________________

Date:                   Results

__________________________________________________________


Remember…

The information provided here is not meant to be a substitute for professional medical advice. These tips are from doctors, nurses and people who have shared their real-life advice; always check with a doctor or other appropriate medical professional you trust before making any healthcare changes.