FILE OF LIFE

Emergency Medical and           

Family Contact Information
_________________________________________________

 

Keep all information current / write in pencil


Name ___________________________ Sex   M   F
 
Address ___________________________

 __________________________________


Date of Birth ________________________

 
Emergency Contact

Name _____________________________

 Address ___________________________

 ___________________________________

Phone # ____________________________

 
Medical Contact Information:
 

Doctor _____________________________

 Phone # ____________________________

 
Special Conditions/ Remarks

 

 Medications:

  
Medication/Date Dosage Frequency :
            
      
      
      
      
 Allergies:

□  Aspirin   □  Morphine

□  Pain Medication:  _________________

□  Insect stings  □  Latex

□  Antibiotic:  ______________________

□  Lidocaine (novacaine)

□  Xray dyes

□  Foods: __________________________

□  Other ___________________________

 
Medical Conditions: Check all that exist

□  No known medical conditions

□  Anemia □  Asthma □  Alzheimer’s

□  Bleeding disorder □  Cancer □  Clotting disorder

□  Deafness □  Diabetes  □  Glaucoma

□  Heart disease: _______________________

□  Hemodialysis  □  High Blood Pressure  □  Kidney Disease

□  Leukemia □  Lymphoma □  Seizures □  Stroke

□  Vision impaired

□  Other ________________________________

Religion: _______________________________

Health Care Proxy on file at_______________________________________ 

Health insurance company _________________

Policy # ________________________________

 Medicaid # _________  Medicare# ___________

File of Life provided by NoVaRHIO
Northern Virginia Regional Health Information Organization
www.novarhio.org