YOUR MEDICAL INFORMATION LIST

Name

Emergency Contact Information

Address

Next of Kin

Phone

Address

Date of Birth

Phone

Social Security #

Relationship

Insurance

Policy #

Primary Physician

Address

Phone

Pharmacy

Address

Phone

Pulmonary Physician

Address

Phone

Medical Equipment Supplier

Name

Address

Phone

Pertinent Medical Diagnosis

Allergies

Other Medical Information

 

 

 

 

 

Living Will—Yes__ No___ DNR—Yes___No___

Location____________________ or attached ____

  

Health Care Surrogate—Yes____No_____

Location__________________ or attached____

PRESCRIPTION MEDICATION LIST

MEDICATION

DOSAGE

FREQUENCY

PHYSICIAN

COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 VITAMIN, MINERAL, AND OTHER OVER-THE-COUNTER REMEDIES 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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