Personal Emergency Medical Form – Help Others Save Your Life

Lifesaving Information When You Have A Medical Emergency


An important component of First Response’s Fall Prevention Home Safety Kit is our “File of Life”.  This Personal Emergency Medical Form can literally save your life when you have a medical emergency at home. We recommend you make copies for the home, car and designated family members or caregivers.

The completed form, which details your contact information, current prescriptions and recent medical history, allows Older Adults to have their complete medical information available to local emergency responder personnel during a medical emergency.  The form is used to provide the patient’s medical information when that individual is not able to speak, is incapacitated, or is not able to remember personal medical information that might be critical to the responders treatment on-site.

What Does the “File of Life” Look Like & Why

First Response’s “File of Life” pak features a clear baggie (10.5-inch by 7-inch) that securely stores the Personal Emergency Medical Form.  A heavy-duty, magnetic clip (that displays the First Response System logo design and toll-free number) is attached to the top of the sealed baggie and is prominently positioned on the refrigerator door.  The double-sided Medical Form (with brightly colored logos) prominently shows through either side of the clear baggie making it easy to find by emergency responders or others in an emergency.

Who Uses The Medical Form During An Emergency


When paramedics or local emergency medical technicians arrive at your home responding to your emergency medical dispatch, the “File of Life” pak located on the refrigerator door, immediately alerts them that the resident has vital medical information securely stored in the clear baggie.  This information allows the technicians to treat the patient on-site in a more effective and safe manner.  It is very common for responders to be trained to look for this medical information at or inside the refrigerator during a home emergency dispatch.

In the event the patient is taken to the emergency room of a nearby hospital for further treatment or observation, it is highly advisable to bring a duplicate copy of the Medical Form to the hospital and have the paramedics offer it upon admittance.  This will further aid hospital personnel in their treatment of your medical condition.

Activate Your Personal Emergency Medical Form


  • Step #1: Complete the entire double-sided form in dark pencil so you can make future revisions and/or updates.
  • Step #2: Insert into the baggie the folded Cover Page so the bright-colored logos show through one side of the clear bag.
  • Step #3: Insert into the baggie the double-sided and folded Medical Form so the logo side shows through the other side of the clear bag.
  • Step #4: Secure the baggie to the refrigerator door (at eye-level height) by using the magnetic clip attached to the top of the baggie.

File Of Life Data

  • Personal Data: user name; date of birth; address; phone numbers
  • Blood Info: blood type; RH factor
  • Emergency Contacts: friends and family
  • Physician Contacts: primary, secondary and specialists; phone numbers and treatment
  • Health Insurance Info: primary, supplemental, medicare, medicaid; name and policy number
  • Allergies Only: antibiotics, pain medications and others
  • Medical History: conditions diagnosed and/or treatment provided
  • Major Surgeries: surgery type, date year, status (last 5 years only)
  • Medical Assistive Devices: medical devices and/or personal emergency response system (PERS)
  • Current Medications: name, dosage and frequency
  • Medication Storage: home storage location
  • Pharmacy Contacts: vendor name, town/city and phone number

Get Help To Complete – Make Copies – Update Form Often


We encourage Older Adults with complex or substantial medical histories and medications to complete the medical information form with assistance from their physician, health care provider and family member caregivers.

It is highly advisable to make duplicate copies of the completed Medical Form for the car, physician appointment, health care provider and family members.

Fill out the entire double-sided form in dark pencil so that you can make future revisions and updates.  We recommend you revise or update your form every 3 to 6 months as a common practice, particularly if your medications or medical conditions change.  When paramedics have complete and up-to-date medical data, they are better prepared to take specific measures to treat patients with special medical conditions appropriately in an emergency.


“I am very uneasy and have had many falls after my surgery. Ordering the First Response system was easy and I even set it up myself. I have had to use my alert button a few times so far. My daughter has even been contacted after I had taken a few falls. My First Response system has worked great each time I’ve needed it!”

Maria V. (valued client since 2009)