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Primary Languages Spoken
Abkhazian
Afar
Afrikaans
Akan
Albanian
American Sign Language (ASL)
Amharic
Arabic
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Armenian
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I am a person with
Alzheimer's
Amplified Pain Syndrome (AMPS)
Amputation / Limb Differences
Anxiety Disorders
Asthma / breathing conditions
Attention Deficit Hyperactivity Disorder (ADHD)
Autism Spectrum Disorder (ASD)
Bipolar Disorder
Blindness / Low Vision
Blood disorders (e.g., hemophilia)
Celiac disease
Cerebral Palsy
Chromosomal Disorder
Chronic Fatigue Syndrome (CFS / ME)
Congenital Hyperinsulinism
Cystic Fibrosis
Deafness / Hearing Loss
Depression
Developmental delays
Diabetes (Type 1 / Type 2)
Down Syndrome
Dyslexia / Learning Disabilities
Ehlers Danlos (EDS)
Epilepsy / Seizure disorders
Heart conditions / pacemaker
Intellectual Disability (ID)
Lupus
Multiple Sclerosis (MS)
Muscular Dystrophy
Other
Post-Traumatic Stress Disorder (PTSD)
POTS
Rare genetic disorders
Sensory processing disorder
Severe allergies (food, insect sting, medication)
Spinal Cord Injury / Paralysis
Supraventricular Tachycardia (SVT)
I am a person with:
My Phone Number
E-mail Address
Contact 1 Name
Contact 1 is my
Care Giver
Child
Family Member
Friend
Grandparent
Guardian
Neighbor
Parent
Partner
Spouse
Other
Contact 1 Phone Number
Contact 2 Name
Contact 2 is my
Care Giver
Child
Family Member
Friend
Grandparent
Guardian
Neighbor
Parent
Partner
Spouse
Other
Contact 2 Phone Number
Would you like to add another contact?
yes
no
3rd Contact's Name
Contact 3 is my
Care Giver
Child
Family Member
Friend
Grandparent
Guardian
Neighbor
Parent
Partner
Spouse
Other
Contact 3 Phone Number
Would you like your address to be shown?
Yes
No
My address is:
123 Address Lane, New Richmond, VA 70126
In case of a crisis, please
Call 911
Call my contact
Other
In a crisis also,
Do you have allergies?
Yes
No
I am allergic to:
Amoxicillin
Aspirin
Azithromycin
Bees
Bleach
Cats
Cephalosporins (e.g., cephalexin, ceftriaxone)
Codeine
Dogs
Erythromycin
Gluten
Heparin
Hydrocodone / Other opioids
Ibuprofen
Insulin
Iodine / Contrast dyes (used in imaging)
Latex
Morphine
Nuts
NSAIDs (e.g., ibuprofen, naproxen)
Peanut
Penicillin (and related beta-lactam antibiotics)
Penicillin derivatives (ampicillin, oxacillin)
Quinolones / Fluoroquinolones (e.g., ciprofloxacin)
Sulfonamides / Sulfa drugs (e.g., sulfamethoxazole)
Tetracyclines (e.g., doxycycline)
Trimethoprim (often combined with sulfonamides)
Vancomycin
Other
I am also allergic to:
Are you currently taking medicines?
Yes
No
Medicines I am currently taking are:
Acetaminophen (Tylenol)
Albuterol (ProAir/Ventolin)
Amlodipine (Norvasc)
Amoxicillin (Amoxil)
Amoxicillin/Clavulanate (Augmentin)
Atorvastatin (Lipitor)
Cetirizine (Zyrtec)
Escitalopram (Lexapro)
Fluticasone (Flonase)
Furosemide (Lasix)
Gabapentin (Neurontin)
Hydrochlorothiazide (HCTZ)
Hydroxychloroquine (Plaquenil)
Ibuprofen (Motrin/Advil)
Levothyroxine (Synthroid)
Lisinopril (Prinivil)
Losartan (Cozaar)
Metformin (Glucophage)
Metoprolol (Toprol XL)
Montelukast (Singulair)
Omeprazole (Prilosec)
Pantoprazole (Protonix)
Prednisone (Deltasone)
Semaglutide (Ozempic/Wegovy)
Sertraline (Zoloft)
Tramadol (Ultram)
Vitamin D (Drisdol)
Other
Medicines, I am also taking:
Do you have a service animal?
Yes
No
My service animal's name is:
Only fill in if you are not human
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