Patient History Form

Having a patient history form can help emergency responders get an accurate history of your medical concerns and conditions in the event that you can’t communicate. Print and fill out the form below.

Patient History Form

EMS Information
Is it a Heart Attack?

Chest Discomfort

Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. 

Discomfort in Other Areas of the Body

Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach.

Shortness of Breath

With or without chest discomfort.

Other Signs

May include breaking out in a cold sweat, nausea or lightheadedness.

Is it a Stroke?

Spot a stroke F.A.S.T.:

  • Face Drooping Does one side of the face droop or is it numb? Ask the person to smile.
  • Arm Weakness Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?
  • Speech Difficulty Is speech slurred, are they unable to speak, or are they hard to understand? Ask the person to repeat a simple sentence, like “the sky is blue.” Is the sentence repeated correctly?

  • Time to call 9-1-1 If the person shows any of these symptoms, even if the symptoms go away, call 9-1-1 and get them to the hospital immediately.

Check out the American Heart Association website for more information.

Vial of Life

The Vial of Life is a program that allows individuals to have their complete medical information ready in their home for emergency personnel to reference during an emergency. This program is used to provide the patient’s medical information when a patient is not able to speak or remember this information.

More details can found at the Vial of Life website. Below is a printable PDF that you can fill our for yourself.

Vial of Life Form

Do-Not-Resuscitate (DNR)

There are currently two Advanced Directive forms that can be accepted by EMS in New York state.

1) Do-Not-Resuscitate Orders (DNR)

The New York State Department of Health has an approved standard Out of Hospital DNR form (DOH-3474) that is legally recognized statewide for DNR requests occurring outside of licensed healthcare facilities. This form is intended for patients not originating from a hospital or nursing home.

For patients with a valid Nonhospital DNR or MOLST form with a DNR order, the Public Health Law allows a standard metal bracelet to be worn by the patient, which includes a caduceus and the words “DO NOT Resusci-tate.” EMS providers should assume that there is a valid DNR in place when a DNR bracelet is identified on a patient.

2) Medical Orders of Life Sustaining Treatment (MOLST)

MOLST is an alternative form for patients to document their end-of-life care preferences and to assure that those preferences are made known to health care providers across the health care delivery system. Unlike the Nonhospital Order Not to Resuscitate, the MOLST form documents DNI orders and orders regarding other life-sustaining treatment, in addition to DNR orders.

MOLST should be honored by EMS agencies, hospitals, nurseing homes, adult homes, hospices and other health care facilities and their health care provider staff. MOLST has been approved by the Office of Mental Health and the Office for People With Developmental Disabilities for use as a non-hospital DNR/DNI form for persons with developmental disabilities, or persons with mental illness, who are incapable of making their own health care decisions or who have a guardian of the person appointed pursuant to Article 81 of the Mental Hygiene Law or Article 17-A of the Surrogate’s Court Procedure Act.

May EMS providers accept living wills or health care proxies?
A living will and/or health care proxy are NOT valid in the pre-hospital setting.

Should I send the DNR or MOLST forms to the Fire Department?
Please do not send any End of Life Directive forms to the Fire Department. We cannot honor them. Both the DNR and MOLST can only be accepted upon EMS arrival at the scene.

Medic Alert Bracelets

An international charity, MedicAlert Foundation was established in 1956 and pioneered the use of medical identification and information services for medical emergencies. The bracelets protect the health and well-being of millions worldwide through the trusted 24/7 emergency support network. They educate emergency responders and health professionals – our partners in everyday emergency situations – about the services that are provided during emergencies. And, they communicate your health information, your wishes, and your directives to ensure you receive the best care possible.

You can find more information by visiting the MedicAlert Foundation, or by viewing the pamphlet below.

MedicAlert Brochure