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Patient Information Sheet

 This is a printable Emergency Medical Information sheet for your personal use.  Please print a copy for each family member, complete and post in an obvious location.  In the event that EMS is dispatched to your home and there is no one able to provide emergency information, EMS will have some basic medical information that may be beneficial to our assessment and treatment of your medical emergency.  Other than at home display you can make copies to carry in your wallet, purse or car.  If you have any questions about the use of this form please call (336) 641-7565. 

Click here to download the Emergency Information Form

 

Do You Know the Warning Signs & Symptoms of…
Stroke, Heart Attack, Hot Weather Emergency and Cold Weather Emergency?

 

Stroke

  • Sudden weakness  or  numbness of the  face, arm or leg, especially on one side
  • Loss of partial or full sight in one or both eyes
  • Difficulty talking or understanding other people, confusion
  • Sudden severe headache
  • Dizziness, loss of balance or coordination or trouble walking

Call 911 RIGHT AWAY

Heart Attack

  • Chest discomfort –pressure, squeezing, fullness, pain
  • Discomfort other areas – one or both arm, back, neck, jaw
  • Shortness of breath
  • Breaking out in a cold sweat, nausea

Call 911 IMMEDIATELY

 

Cold Weather Emergency – Hypothermia

  • Older adults can lose body heat very fast and a big chill can turn into a dangerous problem called hypothermia.  This is what happens when your body temperature gets too low.  Here are a few steps to lower your chances of getting hypothermia.
  • Dress warmly, even if you are staying indoors.  Wear lose layers outdoors that include a hat, gloves and scarf when outdoors.
  • Set your thermostat to 68 degrees or higher.
  • Keep active, eat properly.
  • Talk with your doctor about health problems and medications that may make it harder to keep warm.
  • If you live alone have a relative, friend or neighbor check on you daily.

Signs & Symptoms of Hypothermia:
*Impaired coordination, stumbling, clumsiness
*Confusion, disorientation, irrational behavior
*Slurred speech
*Cold, pale skin
* Shivering
*Sleepiness
Call 911 IMMEDIATELY

Carbon Monoxide Poisoning – The “silent killer”, odorless and cannot be seen

  • Headache
  • Dizziness
  • Difficulty breathing
  • Nausea/vomiting
  • Cyanosis
  • Confusion, lethargic, disoriented
  • Seizures
  • Unresponsive

Call 911 IMMEDIATELY

 

Heat Exhaustion & Heat Stroke – Hyperthermia

Practice heat safety measures.  Do not spend too much time in the hot sun…do outside work during early morning or late evening hours. Wear lightweight, light colored, loose fitting clothes.  Take frequent breaks in the shade.  Keep well hydrated.
Heat Exhaustion

  • Fatigue, weakness, nausea, headache
  • Thirst
  • Muscle aches and cramps
  • Confusion, anxiety, agitation
  • Drenching sweats often accompanied by cold, clammy skin
  • Slow or weak pulse
  • Dizziness, fainting

Heat exhaustion requires medical attention but is not usually life threatening
Call 911 IMMEDIATELY

Heat Stroke

  • Nausea and vomiting
  • Headache
  • Vertigo
  • Fatigue
  • Hot, flushed, dry skin
  • Rapid heart rate
  • Decreased sweating and urination
  • Shortness of breath
  • Increased body temperature (104-106 degrees)
  • Confusion or loss of consciousness
  • Seizures

Heat stroke can occur suddenly without symptoms of heat exhaustion
Call 911 IMMEDIATELY