HEALTH/MEDICAL INFORMATION

Emergency contact:

Name _________________________________________________

address _______________________________________________

______________________________________________________

Phone number _________________________________________

Primary care physician:

Name _________________________________________________

address _______________________________________________

______________________________________________________

Phone number _________________________________________

Blood type: __________________________________________

Special medications: __________________________________

______________________________________________________

Health (physical or mental) issues affecting work:

______________________________________________________

______________________________________________________

 

SOURCE: Adapted from Ron Krannich, Ph.D., The Re-Entry Employment and Life Skills Pocket Guide (Manassas Park: Impact Publications), page 3. Copyright 2009. All rights reserved. Copying strictly forbidden.