"Vial of L.i.f.e. Form"

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VIAL OF L.I.F.E.
LIFE SAVING INFORMATION FOR EMERGENCIES
I certify that the information on this form is accurate and up-to-date. I also understand that
emergency personnel may rely on this information. I agree not to hold emergency personnel
responsible for inaccurate or out-of-date information.
PLEASE PRINT
DATE COMPLETED/UPDATED________________ SIGNATURE_____________________________
PATIENT INFORMATION:
Primary Language:
Name:
Male/Female:
Date of Birth:
Social Security Number:
Address:
City:
State:
Zip Code:
Home Phone: (
)
Cell Phone: (
)
HEALTH INFORMATION:
Primary Medical Problems:
Any disabilities:
No
Yes, Describe:
Previous Medical Problems: (Check all that apply):
Heart
Epilepsy
Stroke
Glaucoma
Asthma
Hemophilia
Diabetes
Hypoglycemia
Seizures
Emphysema
HIV/AIDS
Anemia
Cancer
Low Blood Pressure
High Blood Pressure
Others:
Do you have a pacemaker?
No
Yes, Model #:_________________ Blood
type:_________
Other implants?
No
Yes, Describe:
Allergies to medications (list):
Other Allergies:
Do you have an Advance Directive?
No
Yes, Location?:
VIAL OF L.I.F.E.
LIFE SAVING INFORMATION FOR EMERGENCIES
I certify that the information on this form is accurate and up-to-date. I also understand that
emergency personnel may rely on this information. I agree not to hold emergency personnel
responsible for inaccurate or out-of-date information.
PLEASE PRINT
DATE COMPLETED/UPDATED________________ SIGNATURE_____________________________
PATIENT INFORMATION:
Primary Language:
Name:
Male/Female:
Date of Birth:
Social Security Number:
Address:
City:
State:
Zip Code:
Home Phone: (
)
Cell Phone: (
)
HEALTH INFORMATION:
Primary Medical Problems:
Any disabilities:
No
Yes, Describe:
Previous Medical Problems: (Check all that apply):
Heart
Epilepsy
Stroke
Glaucoma
Asthma
Hemophilia
Diabetes
Hypoglycemia
Seizures
Emphysema
HIV/AIDS
Anemia
Cancer
Low Blood Pressure
High Blood Pressure
Others:
Do you have a pacemaker?
No
Yes, Model #:_________________ Blood
type:_________
Other implants?
No
Yes, Describe:
Allergies to medications (list):
Other Allergies:
Do you have an Advance Directive?
No
Yes, Location?:
Do you have a Medical Power of Attorney?
No
Yes, Location?:
MEDICATIONS:
DRUG
DOSE
FREQUENCY
DRUG
DOSE
FREQUENCY
1.
5.
2.
6.
3.
7.
4.
(see attached list)
PREFERRED PHARMACY:
PHONE:_____________________
HEALTHCARE PROVIDER INFORMATION:
1
Doctor’s Name:
Phone:
st
2
Doctor’s Name:
Phone:
nd
Hospital Preference:
Have you been a patient there?
No
Yes, Last Admission:
Medicare #:
Medicaid #:
Health Insurance:
Policy #:
EMERGENCY REFERENCES:
1
Name:
Phone: (
)
ST
Address:
Relationship:
2
Name:
Phone: (
)
nd
Address:
Relationship:
Please write below any comments or instructions that would be helpful to emergency
responders in assisting you during a personal emergency. Attach a photo of yourself so
emergency personnel can match the information provided to the correct person.
ADDITIONAL INFORMATION:
PLACE  
PHOTO  
HERE  
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