Medical Info system

Need a basic medical info system which can give information about a person in case of emergency. Should work like a membersystem so that each person has his own username and password. The admin and the user can edit data. Only the admin can open a new user, no need to add payment systems and sign up. It is a simple system based on a form with extensive medical information(see attachment. When logged in the form is shown and the user can edit his/hers data. Data must be in a SQL database. This system will be part of an other website (engine of information) and may be extended later on. The database must have the fields mentioned in the form and 6 extra fields to be named by the admin. Must be possible to work with more languages (mulilanguage) like english, dutch, french, spanish and german. Change of language with a flag of the language.