Personal Medical Information Form
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
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.
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.
The KIWY form
is not intended to replace hardcopy or electronic medical records, but is an
interim communication tool to assist individuals as they navigate a potentially
complex system of temporary support, housing, and clinical services. Clinicians
are encouraged to adapt format and content as necessary to best serve the
specific situation, population, and clinical care needs. The form provided is
intended to serve as a basic tool, providing a framework for more specific
suggested that care providers photocopy the document after an
individual receives care, in order to maintain a record of who was seen and what
treatment was provided. The original form is intended to remain with the
individual during the time they are displaced. The form can serve as an
interim summary when normal care can be resumed.