Vial Of Life Form
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1
2VIAL OF LIFE
To assist EMS in case of a medical emergency, please complete both sides of this form and
place it in the pill bottle. Print your name on one Vial of Life label, peel off the backing and
place it on the pill bottle. Store the pill bottle on the top right shelf of your refrigerator. Place
other stickers on your refrigerator door and the front door of your house. Please print clearly
and revise information periodically.
Name ________________________________________________________ Sex:
Address ___________________________________________________________________
Telephone ____________________________ Date of Birth __________________________
Doctor __________________________________ Dr.’s Phone _______________________
Allergies: Medications ________________________________________________________
Food _____________________________________________________________
Latex: _______
Other ______________________________________________
Check below the conditions that you have had in the past or have now:
AIDS/HIV
Emphysema, Chronic bronchitis
Kidney disease
Anemia
Glaucoma
Seizures
Asthma
Heart condition
Stroke
Cancer
_____________
Hepatitis, Liver disease
Tuberculosis
(type)
Diabetes
High blood pressure
Ulcers
Other _____________________________________________________________________
Pacemaker
Defibrillator
Insulin pump
Contact lenses
Dentures
Prostheses
List all prescription and over the counter medications you are currently taking:
Name
Strength
Times per day
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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Parent category: Business