Medical Card Form
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1
2MedCard for:
Always ask:
MedCard for:
My Health Conditions:
Always ask:
My Health Conditions:
1.
What is the name of the
Arthritis
Liver problems
Name:
medicine? What is it for?
1.
What is the name of the
Arthritis
Diabetes
Joint replacement
Liver problems
Name:
medicine? What is it for?
Cancer
Diabetes
Contact lenses
Joint replacement
2.
How and when do I take
Stroke
Dentures/partials
Cancer
Contact lenses
it? How long do I take it?
2.
How and when do I take
Date of birth:
Seizures
Stroke
Lens implant (in my eye)
Dentures/partials
it? How long do I take it?
Date of birth:
Lung problems
Pacemaker (for my heart)
3.
Do I need to stay away
Seizures
Lens implant (in my eye)
Phone:
from any foods, drinks,
Heart problems
Lung problems
Defibrillator (for my heart)
Pacemaker (for my heart)
3.
Do I need to stay away
Phone:
other medicines or activities
from any foods, drinks,
High blood pressure
Heart problems
Hearing aid
Defibrillator (for my heart)
Emergency Contact
while I take this medicine?
other medicines or activities
Kidney problems
High blood pressure
Other:
Hearing aid
Emergency Contact
while I take this medicine?
Kidney problems
Other:
Do you smoke? Last quit attempt __/__/___
4.
Are there any side
Name:
Advance Directives I Have
effects? What do I do if
4.
Are there any side
Name:
Advance Directives I Have
they happen?
Phone:
Living Will
effects? What do I do if
they happen?
Phone:
Durable Power of Attorney for Health Care
Living Will
5.
Where can I find out
Neither
Durable Power of Attorney for Health Care
more about this medicine?
To get more cards contact the
5.
Where can I find out
Neither
Iowa Healthcare Collaborative at
more about this medicine?
To get more cards contact the
Iowa Healthcare Collaborative at
Past Surgeries (Operations)
Year
My Doctor and Pharmacy
Past Surgeries (Operations)
Year
My Doctor and Pharmacy
Doctor’s Name:
Doctor’s Name:
Doctor’s Phone Number:
Doctor’s Phone Number:
Pharmacy Name:
Pharmacy Name:
Pharmacy Phone Number:
Pharmacy Phone Number:
Other Doctors:
(specialists)
Other Doctors:
(specialists)
Allergies
Reaction
Allergies
Reaction
(Medicine, Food, Latex, other)
(What happens)
(Medicine, Food, Latex, other)
(What happens)
Vaccination Dates:
Flu:____________________________
Vaccination Dates:
Flu:____________________________
Tetanus:________________
Pneumonia:______________________
Tetanus:________________
Pneumonia:______________________
MMR:__________________
Tetanus/diphtheria:________________
MMR:__________________
Tetanus/diphtheria:________________
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Parent category: Life