Vial Of Life Medical Information Form - Valley Park Fire District Page 3
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3Medical Information
Allergies:
No known drug allergies
Blood Type: ____________ Height: ____________ Weight: ____________
_______________________________________________________________
YES
NO
Do you wear contacts or eyeglasses?
_______________________________________________________________
_______________________________________________________________
If yes, please specify: ___________________
Medications:
YES
NO
Do you have hearing loss?
Where are your medications kept? ___________________________________
YES
If yes, do you wear hearing aids?
NO
If hearing aids are worn, (check one)
Left,
Right, or
Both ear(s)?
Medication name
Dosage
Frequency
Do you wear dentures?
YES
NO
If yes, do you wear (check one)
Upper,
Lower, or
Both
YES
NO
Are you able to walk without assistance?
If no, what type of assistance do you utilize? ______________________________
Medical History
(Please include surgeries and approximate dates)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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Parent category: Business