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Primary Languages Spoken

AbkhazianAfarAfrikaansAkanAlbanianAmerican Sign Language (ASL)AmharicArabicAragoneseArmenianAssameseAvaricAvestanAymaraAzerbaijaniBambaraBashkirBasqueBelarusianBengaliBihariBislamaBosnianBretonBritish Sign Language (BSL)BulgarianBurmeseCatalanChamorroChechenChichewaChineseChurch SlavicChuvashCornishCorsicanCreeCroatianCzechDanishDivehiDutchDzongkhaEnglishEsperantoEstonianEweFaroeseFijianFinnishFrenchFrench Sign Language (LSF)FulahGalicianGandaGermanGreekGuaraniGujaratiHaitianHausaHebrewHereroHindiHiri MotuHungarianIcelandicIdoIgboIndonesianInterlingua (International Auxiliary Language Association)InterlingueInuktitutInupiaqIrishItalianJapaneseJavaneseKalaallisutKannadaKanuriKartuliKashmiriKazakhKhmerKikuyuKinyarwandaKirghizKirundiKomiKongoKoreanKurdishKwanyamaLaoLatinLatvianLimburgishLingalaLithuanianLuba-KatangaLuxembourgishMacedonianMalagasyMalayMalayalamMalteseManxMaoriMarathiMarshalleseMongolianNauruNavajoNdongaNepaliNorth NdebeleNorthern SamiNorwegianNorwegian BokmalNorwegian NynorskOccitanOjibwaOriyaOromoOssetianPaliPanjabiPashtoPersianPolishPortugueseQuechuaRaeto-RomanceRomanianRussianSamoanSangoSanskritSardinianScottish GaelicSerbianShonaSichuan YiSindhiSinhalaSlovakSlovenianSomaliSouth NdebeleSouthern SothoSpanishSundaneseSwahiliSwatiSwedishTagalogTahitianTajikTamilTatarTeluguThaiTibetanTigrinyaTongaTsongaTswanaTurkishTurkmenTwiUighurUkrainianUrduUzbekVendaVietnameseVolapukWalloonWelshWestern FrisianWolofXhosaYiddishYorubaZhuangZulu

I am a person with

Alzheimer'sAmplified Pain Syndrome (AMPS)Amputation / Limb DifferencesAnxiety DisordersAsthma / breathing conditionsAttention Deficit Hyperactivity Disorder (ADHD)Autism Spectrum Disorder (ASD)Bipolar DisorderBlindness / Low VisionBlood disorders (e.g., hemophilia)Celiac diseaseCerebral PalsyChromosomal DisorderChronic Fatigue Syndrome (CFS / ME)Congenital HyperinsulinismCystic FibrosisDeafness / Hearing LossDepressionDevelopmental delaysDiabetes (Type 1 / Type 2)Down SyndromeDyslexia / Learning DisabilitiesEhlers Danlos (EDS)Epilepsy / Seizure disordersHeart conditions / pacemakerIntellectual Disability (ID)LupusMultiple Sclerosis (MS)Muscular DystrophyOtherPost-Traumatic Stress Disorder (PTSD)POTSRare genetic disordersSensory processing disorderSevere allergies (food, insect sting, medication)Spinal Cord Injury / ParalysisSupraventricular Tachycardia (SVT)

I am a person with:

My Phone Number

E-mail Address

Contact 1 Name

Contact 1 is my

Care GiverChild

Family MemberFriend

GrandparentGuardian

NeighborParent

PartnerSpouse

Other

Contact 1 Phone Number

Contact 2 Name

Contact 2 is my

Care GiverChild

Family MemberFriend

GrandparentGuardian

NeighborParent

PartnerSpouse

Other

Contact 2 Phone Number

Would you like to add another contact?

yesno

3rd Contact's Name

Contact 3 is my

Care GiverChild

Family MemberFriend

GrandparentGuardian

NeighborParent

PartnerSpouse

Other

Contact 3 Phone Number

Would you like your address to be shown?

YesNo

My address is:

123 Address Lane, New Richmond, VA 70126

In case of a crisis, please

Call 911Call my contactOther

In a crisis also,

Do you have allergies?

YesNo

I am allergic to:

AmoxicillinAspirinAzithromycinBeesBleachCatsCephalosporins (e.g., cephalexin, ceftriaxone)CodeineDogsErythromycinGlutenHeparinHydrocodone / Other opioidsIbuprofenInsulinIodine / Contrast dyes (used in imaging)LatexMorphineNutsNSAIDs (e.g., ibuprofen, naproxen)PeanutPenicillin (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)VancomycinOther

I am also allergic to:

Are you currently taking medicines?

YesNo

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?

YesNo

My service animal's name is:

Only fill in if you are not human