Vial Of L.i.f.e Form - Lifesaving Information For Emergencies Page 2
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1
2Date Completed: _______________
VIAL OF LIFE
MEDICAL INFORMATION FORM: This form should be readily available for responding fire crews.
NAME:_______________________________________
Phone #_____________________________
ADDRESS:________________________________________________________________________________
DATE OF BIRTH:__________________________
AGE:______________
EMERGENCY CONTACT NAME______________________
EMERGENCY CONTACT #:___________
PRIMARY DOCTOR NAME:______________________ DOCTORS PHONE #_______________________
CURRENT MEDICAL HISTORY: ____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
CURRENT MEDICAL CONDITIONS:
( ) AIDS/HIV
( ) Diabetes
( )High Blood Pressure
( ) Anemia
( ) Dementia
( ) Internal Defibrillator
( ) Asthma
( ) Emphysema
( ) Low Blood Pressure
( ) Angina
( ) Epilepsy
( ) Pacemaker
( ) Breathing Problems
( ) Glaucoma
( ) Seizures
( ) Cancer
( ) Heart Condition
( ) Stroke
( ) COPD
( ) Hearing Problems
( ) Tuberculosis
( ) Other
( ) Hepatitis
CURRENT MEDICATIONS AND DOSAGES:
MEDICATION
DOSAGE
LOCATION
ALLERGIES:
ANY ADDITIONAL INFORMATION:
I certify that the information on these forms is accurate and up-to-date. I authorize medical care for myself and my family in the event
of illness or injury.
Signature: ________________________
Print Name:______________________________________
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