BEFORE FILLING OUT THIS FORM, PLEASE SAVE OR PRINT SEVERAL COPIES OF IT!

FOLD HERE

FOLD HERE

Directions
1.	Save or print several blank copies of this form for future use.
2.	When filling out this form on your Computer, use the TAB key to move to a new line and/or point & click in the shaded areas with your mouse. 
3.	On one copy, fill in the blanks, using the “Additional Information” section on this part of the form if you need more space.
4.	Copy the completed form. 
     a.  Cut along the scissors line.
     b.  Fold the form to fit into a wallet or
    large luggage tag (it will be  the 
    size of a credit card when folded
    in fourths.)
5.	Highlight the words “Medical Information” at the top of the form.
6.	Remember to list any changes in your medications so that this record is always current.
7.	Keep this record with you, even when you are not carrying your full wallet.
Remember
1.	Always have this information with you, 
      so you have it in an emergency.
2.	Give a copy to all your doctors, your pharmacist and your dentist, so they are kept up-to-date about your medications.
3.	Revise this list whenever your medications change, so you remember what you are currently taking. 	  
MEDICAL INFORMATION
	
	  Name:	     		
	  Address:	     		
		     		
				
	  Date of Birth:	     		
			
	  Social Security #: 	     		
	        (optional)		
	  Insurance Information:	     		
		     		
	  Blood Type:	     		
	  Drug or Food Allergies:	     		
	  	     		
				
	  Medical Conditions:	     		
	  	     		
		     		
		     		
		     		
				
	Medications, Vitamins, Herbs and Supplements	
Dose	
Frequency	
	     	     	     	
	     	     	     	
	     	     	     	
	     	     	     	
	     	     	     	
	     	     	     	
	     	     	     	
	     	     	     	
		(Continue on next page)		
	
      IN CASE OF EMERGENCY
		
	  Physician			
	  Name:	     		
	  Tel:	     		
				
	  Contact Persons			
	  Name:	     		
	  Tel:	     		
	  Name:	     		
	  Tel:	     		
		Copyright  1999 Ann Steiner, Ph.D.		
	  Date Updated:	     		

Cut,    fold    and    keep    this    in    your    wallet    at    all    times

BEFORE FILLING OUT THIS FORM, PLEASE SAVE OR PRINT SEVERAL COPIES OF IT!

Medical Information Continued
	
	Medications	Dose	Freq.		
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
	Vitamins, Herbs  and Supplements				
		Dose	Freq.		
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
				
	Durable Power of Attorney 
for Health Care Decisions:
(Optional)		

	Name:	     		
	Tel:	     		
	Name:	     		
	Tel:	     		
			
	Copyright  1999 Ann Steiner, Ph.D.		
	
Note:  This document is copyrighted. It is being made available without charge for personal use to individuals. Commercial use including reproduction, or use by organizations and for-profit businesses is prohibited without the author’s written consent. For copies visit: www.DrSteiner.com		

			

			

					

Additional Information
	
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		
	     		

Other Physicians:
		
	Physician			
	Name:	     		
	Tel:	     		
				
	Physician			
	Name:	     		
	Tel:	     		
				
	Date Updated:	     		

				

Cut,    fold    and    keep    this    in    your    wallet    at    all    times