Dr. Steiner's Psychotherapy Tools

Medical Information Form

  1. Introduction to the Medical Information Form™
  2. What the Medical Information Form™ Looks Like
  3. How to Download
  4. How to Fill Out
  5. How to Use

How to Fill Out the Medical Information Form™


1. Download the Medical Information Form onto your computer.

2. Take a tour of your home. Gather up all the medications, herbs, vitamins and supplements you take on a regular basis. After you've collected all the bottles, set them out on the table and take a big breath. You are now ready to copy the names onto the form.

3. List the name, dosage, and how often you take the medication. The time invested in filling out the form is not fun. It forces us to confront unpleasant realities. Nevertheless, that investment of a few uncomfortable minutes can increase your safety and feeling of security.

4. Fill in the Medical Information Form™ and give copies to your family members and medical team. Tell family members and anyone who assists you where the file is stored on your computer so they can get the latest information in the event of an emergency.

5. The form is especially important for children and adults who are taking prescription medications. Having the latest list saves the doctor's time and can speed appropriate treatment in an emergency.

6. Space has been left for those who have special needs or who want to list the person named in their Durable Power for Health Care Decisions, a legal document that spells out your wishes about medical treatment if you are unable to speak for yourself.

7. When changing information on the Medical Information Form™ point with your mouse and double click to highlight the shaded area. Type in new information (this deletes your old information on this line.)

8. If you want, you can view a sample of a filled-out and folded form.


1. Keep this form as up to date as possible. Every time you change medications, supplements or dosages, it is important to write the new information on your Medical Information Form™.

2. Once you copy the form onto your computer no one except those you decide to give a copy of the completed form to will be able to see your private medical information.

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© Ann Steiner, Ph.D. All rights reserved. Reproduction without the author's written consent is prohibited.

Last Updated: April 6, 2016