Vial Of Life Medical Information Sheet - Dartmouth Hitchcock
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1Vial of
LIFE
Medical Information Sheet
Lifesaving Information For Emergencies
Date completed:
MEDICAL CONDITIONS:
CURRENT
(check all that exist)
MEDICATIONS:
Name:
__ No medical conditions
As of (date)___________
__ Angina
_____________________
Address:
__ Asthma
__ Bleeding / clotting disorder
Fill in your medications
Home Phone:
__ Blindness
in the box below.
If you need more
__ Cancer (type)____________
Lives With:
room, please include
__________________________
a complete list on a
Date of Birth:
separate sheet and
__ COPD / emphysema
place in the vial.
__ Diabetes / hypoglycemia
Eye Color:
Hair Color:
__ Heart attack
__ Hepatitis
Sex:
Male
Female
List Current
__ HIV / AIDS
Medications:
Hospital Preference:
__ Kidney problems
(Example: Lasix 20 Mg.
__ Memory problem
1 tablet 2x/day)
Primary Physician:
__ Osteoporosis / fractures
__ High blood pressure
Phone:
__ Pacemaker
__ Seizures
Other Physician:
__ Severe hearing loss
__ Stroke
Phone:
__ Vision problems
Contact lens:
Emergency Contact:
___ yes ___ no
Name:
__ Other__________________
__________________________
Phone:
ALLERGIES:
Address:
(check all that exist)
__ No known allergies
Relationship:
__ Aspirin
__ Codeine
I have the following:
__ Demerol
____Durable Power of Attorney for Health Care or Health Care Proxy
__ Insect stings
A “Durable Power of Attorney for Health Care” or “Health Care Proxy”
__ Latex
is a written statement that assigns a particular person to share your
__ Morphine
wishes and make decisions for you about your health care if you are
__ Penicillin
unconscious or incapacitated.
__ Sulfa
____Advance Directive or Living Will
__ Other __________________
“Advance Directives” or “Living Wills” are written statements that
reflect your wishes and allow a health care team to understand
__________________________
your goals of care for medical interventions and care at the end
of life, should you be unconscious or incapacitated.
For a replacement medical information form:
____Other important medical documentation
Visit:
such as copies of orders regarding life-sustaining treatment (Do
Call: (603) 650-5789
Not Resuscitate or DNR orders), pacemaker or ICD information,
or implant information.
Courtesy of
Copies of the above documents can be found in this specific
location in my home:
___________________________________________________
___________________________________________________
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