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patient information form


This Medical History Form asks the most pertinent questions for an emergency situation.  It is comprehensive enough to avoid accidental harm while still brief enough to not slow down the flow of the response process.  It would serve as an example to other health departments looking to develop medical histoy forms for patients in an emergency situation. 


Medical Countermeasure (MCM) Toolkit

Keyword Area:

Strategic Planning


Institutional Author:

North Central District Health Department




The NACCHO Toolbox is a repository of available resources to help local public health practitioners. Tools are produced by local, state, and federal agencies, as well as academic institutions and other stakeholders. The contents of this Toolbox are solely the responsibility of the authors and do not necessarily reflect any official recommendations of NACCHO. NACCHO makes no express or implied warranty with respect to the contents and disclaims liability for any damages arising from or connected to the use of the material in this Toolbox.