1. Basic information:
Full name
(with surname in all caps):
Health insurance
information:
(a) Provider:
(b) Group
number: (c) Policy number:
(d) Name of policy
holder: (e)My relationship to policy holder:
Date of birth:
Sex:
Next of kin and/or power of attorney for health care
(relationships noted):
Addresses and phone numbers (mine and that of next of kin):
My full mailing address:
Phone(s):
Next of kin full mailing address and phone contact numbers:
(x) Same as above (i.e. same as mine)
(x) Other:
Primary Care Physician and contact information:
Pharmacy name and phone number:
2. Past Medical History summary:
Medical diagnoses/conditions (all known major diagnoses):
Past surgical history with
dates, locations (includes reason for surgery and outcomes):
Allergies (especially
medications) and the way I have reacted to them in the past:
Names and specialties of
physicians who are still following me (includes addresses and contact
information):
3.
Current medications:
Prescription medications (dose and
number of times per day taken):
Specialized
treatments (includes chemotherapy, drug trials, medication
injections):
Over-the-counter remedies ( e.g. Tylenol, Gravol,
etc):
Herbal medications, vitamins and
supplements:
Cigarettes per day:
Alcohol
consumption per day (average):Street drugs (e.g. marijuana, cocaine,
etc.):
4. Medical
tests summarized:
Most recent bloodwork (date and summary
of findings):
Summary
from currently relevant written report(s) of xrays, MRIs, CTs, etc:
Photocopy of recent
electrocardiogram (ECG) attached? (x) NO (x) YES
5. Advanced care directives - Important: All relevant
directives are circled [x] and initialed:
(x) All medical measures may be taken - including
life support if I am unable to say otherwise
(x) ♥Organ
donation authorized ♥
(x) No CPR, no Ventilation, no Life
Support
(x) No blood transfusions
(x) DNR
- "Do Not Resuscitate"
Signature:
__________________________________________________Date_______________