Emergency Contact & Health Information Form Personal Information Code status Full Limitied DNR(do not resuscitate) First Name Last Name Maiden Name Address City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Country Home Phone Work Phone Cell Phone Date of Birth Email Address Gender Select Male Female Gender Assigned at Birth Other Sexually active Yes No Height Inches Weight lbs kgs Ethnicity/Race Select African American or Black Alaska Native Amecian Indian Asian Caucasian Hispanic Latino Birthmark/Scars Blood/RH Type A+ A- B+ B- O+ O- AB+ AB- Marital Status Married Divorced Separated Single Widowed Occupation Primary/Preferred Language Primary Health Insurance Carrier Policy Number/Group Secondary Health Insurance Carrier Policy Number SUBMIT