medical info form

[Guest guest]

http://scican.net/~haxton/medinfo.htm

Date of information (to indicate to medical personnel how current is this

information)

General Information

Name

Address

Telephone Number

Your place of employment

Address of employment

Telephone Number of employment

Date of birth

Next of Kin

Relationship

Address

Telephone Number

Place of employment

Address of employment

Telephone Number of employment

Insurance Information

Name of company

All important insurance numbers

Children (list each)

Address

Telephone Number

(Their Date of birth if you are a woman & also list miscarriages, abortions,

etc.)

Primary physician or family doctor

Address

Telephone Number

(You can include patient ID number if you know it)

Other Physicians

(Specialty)

Addresses

Telephone Number

(You can include patient ID number if you know it)

What they are treating you for.

Eye care

(Doctor or eye clinic)

Address

Telephone Number

Dentist

Address

Telephone Number

Pharmacy

Address

Telephone Number

Basic health information

Blood type

Dental - Bridges, braces, etc.

Glasses/contact lenses

Date of menstrual period

Special Information

I would like to be an organ donor in the event of my death

!!!ATTENTION!!! DO NOT GIVE - List medications that should not be given.

List substances/allergens you have had a strong reaction to in the past

Preference - drugs or treatments you would rather not have

Complete Health Information

Past Medical Conditions

Detail medical history from childhood to present

Surgeries and treating physicians

Broken bones and treating physicians

All diseases, conditions, etc. presently being treated for and diagnosed

with

List symptoms of each ailment ESPECIALLY unusual symptoms.

Current Meds

Temporary Meds Name of each med & strength

Pharmacy

Prescribing Physician

Why you are taking this medication

Routine Daily Meds

Name of each med & strength

Pharmacy

Prescribing Physician

Why you are taking this medication

Meds Taken as Needed

Name of each med & strength

Pharmacy

Prescribing Physician

Why you are taking this medication