College Student's Emergency Information Sheet

Post the following information on a bulletin board, by the phone or another handy place in your dorm room/apartment. Make sure your roommates know about this sheet and its location in case of an emergency.

If you’d like a detailed form to track your health, check out this form from the University of Texas.

Also, along with your medical history, print and fill in a Medical Appointment Information form to help track each doctor or medical appointment. After each appointment, add all medical notes to your personal medical folder.

Click here to print out this sheet.

Emergency Information Sheet

Your Name
Date of birth
Social Security Number (optional)
Current address
Cell phone
Current phone (if different from cell)
Home address
Home phone
Special medical conditions

Emergency Contacts

Father - Work and Home
Mother - Work and Home
Other - Work and Home

Your Medical History (date and nature of illnesses, surgeries)
Illness and Date
Illness and Date
Illness and Date
Illness and Date
Allergies

Family Doctor and Phone
Dentist and Phone
Optometrist and Phone
Other Names and Phone

Health Insurance Information
Insurer and Phone
Policy Holder’s Name and Relationship
Policy Number

Vaccinations

Talk to your school’s health services about health requirements. Not all listed vaccinations are required or necessary to have more than once. Also, if you plan to travel abroad during college you may need extra vaccinations and/or documentation of vaccinations.

Type Date #1 Date #2 Date #3 Date #4
Chickenpox (Varicella)
DTP
(Diphtheria, Tetanus, Pertussis)
Hepatitis A
Hepatitis B
Influenza
Meningococcus
MMR
(Measles, Mumps, Rubella)
Polio
Rabies
Tetanus
Tuberculosis (test) Date: Results: Date: Results
Other
Other