Vial Of Life Form

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VIAL OF LIFE
Completed On:
______/________/________
Instructions
Fill out this form as completely as possible (print clearly, please). If you need assistance with certain information,
please contact your doctor and/or ask a neighbor for help. Fold this form and put it inside the vial. Place the vial on
the top shelf of your refrigerator or refrigerator door. If you are able to speak, inform any responding emergency
personnel that you have a vial. If any medical information changes, it is important to update this form. Additional
forms are available from Kevin's Pharmacy. To download, go to:
Name:________________________________________________________________________
Date of birth: ___/___/_______
Address:______________________________________________________________________
City:___________________
Zip: _____________
Age:__________
Sex: M F
S.S. #:__________________
Telephone: (
)______________
Blood Type:_____________
Height:________
Weight:__________
Glasses: Yes No
Language spoken:_______________________________
Dentures: Yes No
When was your last tetanus booster shot? ___/___/____
Do you carry an EpiPen: Yes No
Current medical conditions (list all ailments)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Past medical conditions:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list all known allergies (medications, environmental, etc.)
______________________________________________________________________________
______________________________________________________________________________
Have you ever suffered from (place a [X] next to all that apply):
[ ] Lung Disorder
[ ] Nervous Disorder [ ] Heart Trouble
[ ] Cancer
[ ] High Blood Pressure
[ ] Diabetes
[ ] Digestive Disorder
[ ] Arthritis
[ ] Kidney Disease
[ ] Hepatitis
[ ] Blood Disease
[ ] Epilepsy
[ ] Other:
______________________________________________________________________________
Your doctor’s name: _________________________
Telephone: (
)______________
Hospital preference: ___________________________________________________________
Emergency contact(s):
Name_________________________________________________________________________
Relationship_______________________
Telephone: (
)______________
Name________________________________________________________________________
Relationship_______________________
Telephone: (
)______________

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