Vial Of Life Packet - Emergency Medical Information Worksheet Page 2
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1
2VIAL OF LIFE
DATE COMPLETED:_________________________
EMERGENCY MEDICAL INFORMATION - FOR RESCUE SQUAD
Sponsored by American Medical Alarms, Inc. - Phone Toll Free (800) 542-0438
FIRST NAME
INITIAL
LAST NAME
SOCIAL SECURITY NUMBER
STREET
CITY
STATE
ZIP
TELEPHONE
DATE OF BIRTH
MALE/FEMALE
HEIGHT
WEIGHT
HAIR COLOR
EYE COLOR
BLOOD TYPE
RELIGION
IF PACEMAKER, MODEL #
DEFIBRILATOR, MODEL #
HEARING AID
DEAF
DENTURES
UNABLE TO SPEAK
L
R
L
R
UPPER LOWER
VISION
GLASSES
CONTACTS
BLIND
ARTIFICIAL EYE
NATIVE LANGUAGE IF NOT ENGLISH
L
R
L
R
IDENTIFYING MARKS:
CIRCLE CONDITIONS YOU HAVE BEEN TREATED FOR IN THE PAST
AIDS
BLOOD PRESSURE
EPILEPSY
HEART CONDITION
TUBERCULOSIS
ANEMIA
CANCER
GLAUCOMA
JAUNDICE
OTHER:
ARTHRITIS
DIABETES
HAY FEVER
SINUS
ASTHMA
INSULIN Y / N
HEPATITIS
STROKE
CURRENTLY BEING TREATED FOR?
CURRENT MEDICATIONS/DOSAGE/FREQUENCY/LOCATED
CURRENT MEDICATIONS/DOSAGE/FREQUENCY/LOCATED
NAME OF DOCTOR
TELEPHONE NUMBER
NAME OF DOCTOR
TELEPHONE NUMBER
NAME OF DOCTOR
TELEPHONE NUMBER
NAME OF DOCTOR
TELEPHONE NUMBER
ALLERGIES TO MEDICATIONS
LAST HOSPITALIZATION
HOSPITAL
LOCATION
YEAR
PATIENT #
LIVING WILL
ORGAN DONER
REFER TO:
REFER TO:
MEDICAL COVERAGE
BLUE CROSS #_______________________ BLUE SHIELD #___________________________
MEDICARE #____________________________
MEDICAID #
OTHER
POLICY #
IN CASE OF EMERGENCY - NOTIFY
RELATIONSHIP
STREET ADDRESS
APT
CITY
STATE
ZIP
PHONE
PLACE ON FRONT OF REFRIGERATOR AND UPDATE AS NEEDED
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