Vial of Life

Complete a separate information sheet for each member of the family. Place completed form(s) in plastic pouch and attach to refrigerator. Update information if physicians and medications change. Record the date of each update on the last page of the form.
Personal Health Information
Name:
Address:
Telephone:		Date of Birth:
Physicians Names & Numbers:
Major Medical Problems:
Current medications: (including over-the-counter (OTC) medications, vitamins, minerals, supplements and herbs)
Where are the medications kept?
Allergies:
Date of last Tetanus Booster:		Blood Type:
Have you ever been treated for:
No - Alzheimers No - Dementia No - Glaucoma No - HIV/AIDS No - Seizures	No - Anemia No - Diabetes No - Heart Condition No - Infectious Disease No - Sickle Cell	No - Angina No - Dialysis No - Hepatitis No - Pacemaker No - Stroke	No - Cancer No - Epilepsy No - High Blood Pressure No - Respiratory No - Tuberculosis
Other
Insurance Information
Health Insurance Company
Telephone:		Plan Number:
Do you have a Living Will?		Where?
Do you have a notarized Do Not Resuscitate order?		Where?
Are you an organ donor?
In Case of an Emergency, Notify
1. Name:		Relationship:
Home Phone: Cell Phone: Work Phone:
2. Name:		Relationship:
Home Phone: Cell Phone: Work Phone:
3. Name:		Relationship:
Home Phone: Cell Phone: Work Phone:
This information was last updated on Friday, May 25, 2012.