Family Emergency Health Information Sheet
PDF Version 
During a flu pandemic or other health emergency, you may be required to provide specific health information about yourself and others in your care to those offering health care services. This information is essential to health care providers when considering how best to treat you and your family. Using the chart below, fill in as much information as possible for each family member.
Name |
Date of Birth |
Provincial
Health
Card
Number |
Blood
Type |
Allergies |
Existing
Medical
Conditions |
Medications
(include
dosage) |
Name and
Contact
Information
for Current
Health Care
Provider(s) |
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List of contacts
| Emergency contact |
| In the event you or your family members become ill, you may wish to have a relative or friend notified of the situation. They may be able to offer additional information to the health care providers treating you or may be able to help with your care. |
| Name: |
Name: |
Telephone Number:
Relationship to you (or your family): |
Telephone Number:
Relationship to you (or your family): |
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| Hospitals |
Name of Hospital:
Telephone Number: |
Name of Hospital:
Telephone Number: |
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| Pharmacy |
Public Health Hotline |
Name of Pharmacy:
Telephone Number: |
Telephone Number: |
If you and/or a family member are ill, you may need others to notify your place of work or any schools your children attend. In addition, during a pandemic, you may need to check periodically to determine if these facilities have closed their operations.
| Work |
Schools |
Name of Contact:
Telephone Number: |
Name of School:
Telephone Number: |
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Name of School:
Telephone Number: |
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