Vial Of L.i.f.e. Form Life Saving Information For Emergencies

VIAL OF L.I.F.E.
LIFE SAVING INFORMATION FOR EMERGENCIES
I certify that the information on this form is accurate and up-to-date. I also understand that
emergency personnel may rely on this information. I agree not to hold emergency personnel
responsible for inaccurate or out-of-date information.
PLEASE PRINT
DATE COMPLETED/UPDATED________________ SIGNATURE_____________________________
PATIENT INFORMATION:
Primary Language:
Name:
Male/Female:
Date of Birth:
Social Security Number:
Address:
City:
State:
Zip Code:
Home Phone: (
)
Cell Phone: (
)
HEALTH INFORMATION:
Primary Medical Problems:
Any disabilities:
No
Yes, Describe:
Previous Medical Problems: (Check all that apply):
Heart
Epilepsy
Stroke
Glaucoma
Asthma
Hemophilia
Diabetes
Hypoglycemia
Seizures
Emphysema
HIV/AIDS
Anemia
Cancer
Low Blood Pressure
High Blood Pressure
Others:
Do you have a pacemaker?
No
Yes, Model #:_________________ Blood
type:_________
Other implants?
No
Yes, Describe:
Allergies to medications (list):
Other Allergies:
Do you have an Advance Directive?
No
Yes, Location?:

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