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

Dr.Steiner's Medical Information Form™

The Medical Information Form™ is easy to use and will help you keep track of your medications, vitamins and supplements. It folds up neatly into your wallet or pocket, and you can change it as often as you need to. And, best of all, it is absolutely free!

Use the links above to learn more about the Medical Information Form™.

Few people remember the names and dosages of the medications, vitamins and supplements they take. Even fewer realize that it can be deadly to mix certain medications with over-the-counter medicines. By keeping your list of all types of medications, your pharmacist and doctors make sure that it is safe to take them together.

Increase your comfort and safety

Example: Yvonne, a recently divorced woman in her 40's decided to get "back in shape." Part of her routine was to go for long walks on a local bike path. One afternoon she simply collapsed. Paramedics were unable to help her and had no information about who to contact in an emergency. This tragedy could have been avoided if she had had a MedForm in her pocket along with her keys.

Example: Amy, a 35 year-old bank teller joined her local gym and began taking exercise classes. After a few months she learned that the heartburn she had was a symptom of a mild heart problem and she began heart medication. After she had the flu she started taking some supplements that were advertised as energy boosters. When she showed her MedForm to her doctor he told her that the combination of the heart medications she was taking and the supplements could cause permanent heart damage.

Example: An older patient described a recent episode with paramedics and ambulance staff, "I didn't want them bothering me and asking me questions, they wanted to know my insurance numbers, which I always know but I botched it and that got me even more upset." The MedForm could have saved her embarrassment and helped her get proper medical care faster.

Dt Steiner's Medical Form

(completed form will be the size of a credit card)

"ICE" - In Case of Emergancy

"ICE" will speak for you when you are not able to. This is a standard procedure all paramedics follow at the scene of an accident when they come across your cell phone.

We all carry our cell phones with names and numbers stored in its memory but nobody, other than ourselves, knows which of these numbers belong to our closest family or friends.

If we were to be involved in an accident or were taken ill, the people attending us would have our cell phone but wouldn't know who to call. This "ICE" (In Case of Emergency) Campaign is designed to help emergency personnel find your emergency contact persons' phone number.

"ICE" is a method of contact during emergency situations. As cell (mobile) phones are carried by the majority of the population, all you need to do is store the number of a contact person or persons who should be contacted during emergency under the name "ICE" ( In Case Of Emergency).

Add this nationally recognized system to your cell phone. In an emergency situation, emergency service personnel and hospital staff will be able to quickly contact the right person by simply dialing the number you have stored as "ICE."
For more than one contact name simply enter ICE1, ICE2 and ICE3 etc. A great idea that will make a difference!

Let's spread the concept of "ICE" by storing an "ICE" number on your cell phones today!

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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