Patient Information Form

Who is this form for?

Anybody. “As they say in the circus –  men, women and children of all ages!” 




Type in the fields of this ‘fillable’ PDF and print multiple copies to keep in your home, office and car for you and your loved ones.


We never know when a medical emergency may strike, anyone may benefit from using this form.   Medical emergencies are stressful and patients, or their family, may not be able to recall this information during an emergency.

It is important for EMS to have an understanding as to a patient’s medical diagnoses, medication, and allergies to food, medication and latex so they can offer appropriate treatment and transport destination options.  

This is especially true with your medication list.  Many people either don’t know the names of all of the medication they are prescribed and/or don’t know the dose.    They identify pills by shape and color which is nearly impossible for EMS or the ED to figure out.   Although a medication list may be in the patient’s chart at the hospital or as a repeat patient in HFD EMS’s computer it may not be current.   As your medication names and doses change make that change on the form or download a new form.  


If you do not have the ability to complete the form and need assistance call HFD at (401) 949-1188 and we will arrange for somebody to assist you.