Cut out this card, fill it in, fold it, and keep it in your wallet or phone case. Show it to any doctor or emergency room staff if you need urgent care.
```
┌─────────────────────────────────────────────────────────────┐
│ PROSTATE CANCER │
│ EMERGENCY MEDICAL CARD │
│ │
│ Name: _______________________________________________ │
│ Date of Birth: ______________________________________ │
│ Emergency Contact: __________________________________ │
│ Emergency Phone: ____________________________________ │
│ │
│ DIAGNOSIS │
│ Prostate cancer — Stage: ______ Gleason: ______ │
│ Grade Group: ______ Date diagnosed: ____________ │
│ │
│ CURRENT TREATMENT │
│ □ Active surveillance │
│ □ Post-surgery (prostatectomy) Date: _______________ │
│ □ Radiation therapy Type: _______ Dates: ______ │
│ □ Hormone therapy Drug: ________ Since: _______ │
│ □ Chemotherapy Drug: ___________ Cycle: _______ │
│ □ Other: ________________________________________ │
│ │
│ CURRENT MEDICATIONS │
│ 1. ________________________________________________ │
│ 2. ________________________________________________ │
│ 3. ________________________________________________ │
│ 4. ________________________________________________ │
│ 5. ________________________________________________ │
│ │
│ ALLERGIES │
│ ________________________________________________________ │
│ ________________________________________________________ │
│ │
│ BLOOD THINNERS: □ Yes □ No Drug: ______________ │
│ PACEMAKER/DEVICE: □ Yes □ No Type: ______________ │
│ IMPLANTS (seeds, spacer, fiducials): □ Yes □ No │
│ │
│ IMPORTANT NOTES │
│ □ Immunocompromised (on chemo) — fever is emergency │
│ □ On ADT — cardiac risk factors present │
│ □ Bone metastases — fracture risk │
│ □ Spinal metastases — watch for cord compression │
│ □ Other: ________________________________________ │
│ │
│ MY DOCTORS │
│ Urologist: ____________________ Ph: ____________ │
│ Radiation Oncologist: __________ Ph: ____________ │
│ Medical Oncologist: ____________ Ph: ____________ │
│ Primary Care: __________________ Ph: ____________ │
│ Cancer Center Nurse Line: ________________________ │
│ │
│ INSURANCE │
│ Plan: _______________________ ID#: _____________ │
│ Group#: _____________________ Ph: ______________ │
│ │
│ Last updated: _______________ │
└─────────────────────────────────────────────────────────────┘
```
Tips:
- Update this card every time your treatment changes
- Take a photo of both sides and store it on your phone
- Share a copy with your emergency contact
- If you are on chemotherapy, always carry this card — emergency room doctors need to know immediately
- If you have bone metastases, make sure ER staff know before they move you