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The Trips and Tramps Sub-committee recommends this form be used by each person on the trip, it can be printed as a A5 doubled form. You should keep this form in a plastic bag in an outside pocket of your pack. NHI No: Full name: Date of birth: Address: Emergency contacts: (1) Name: Relationship: Mobile: Landline: (2) Name: Relationship: Mobile: Landline: Health conditions and allergies which could cause an emergency: Medications carried for these emergencies (state which medication for which emergency): How are these medications to be administered?: Please keep these medications and this Personal Information form in a see-through waterproof plastic bag in a readily-accessible place in your pack, so your companions can find them easily if you are not capable of doing so as a result of the emergency. Please go to the other side of this form to complete the information. PERSONAL INFORMATION TO BE USED IN EMERGENCIES – Page 2 If I suffer an emergency which requires medical help, please give this form to the medical staff. This information will help medical staff in diagnosing and treating my condition. 1) Routine medication In order for medical personnel to give me the most appropriate treatment in case of an emergency, I list below the routine medications I am taking, and also some medical/surgical history which may be important. My GP: GP's Phone: Name of medication and Dose rate Items and dates of my medical or surgical history which may be important: 2) Allergies to medication: I am allergic to the following medications: Sticking Plaster: am/am not allergic to sticking plaster (please circle one or the other) ... Signed: Date:
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