Keep It With You personal medical information form
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Keep It With You personal medical information form

Filetype[PDF-70.59 KB]

  • English

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      In an emergency situation, people may not be able to get to their medical records. The “Keep It With You” (KIWY) Personal Medical Information Form is intended to be a voluntary and temporary record that lists medical care and other health information for people who need care during disasters and similar situations. It is important for health care workers to have a simple and reliable way to learn information about past and new health concerns for people receiving help.


      Please print out Side 1 & 2 of the KIWY Personal Medical Information Form. The KIWY form should be copied so that it is on 2 sides of one piece of paper.

      Please fill out as much as you can on the form. It is okay if you don’t fill out every space. You might want to use a pencil if some information will change, such as your address. Some of the information will be filled out by a health care worker, like “Active Diagnoses” and “Healthcare Encounters” information. If you have an immunization card listing the shots you have recently had, please staple it to the KIWY form.

      The KIWY form can be folded and placed in a plastic bag for safe keeping.

      Last reviewed June 9, 2006 Last Modified 9/12/2005 11:49 AM


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