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Personal Medical Information Form

Several people have recently asked for a copy of the med. info form I use. I have asked them to send me their emails or to email me at my home email, as I can't send attachments in PMs. Apparently they are afraid to do so. I am posting a modified version here (site won't let me do charts, etc.)Feel free to use/change as needed.

NAME___________________________________ DATE OF BIRTH: _________

Home Address_______________________________________________________________________________________
Home phone ____________________ Cell ____________________ Work Location & phone: _____________________
Insurance Company(s) and Policy/ID Number Phone #

Emergency contacts-
1ST CONTACT_____________________________Relationship_____ PHONE #S_________________
List additional contacts and #s (best to have 2 or 3 at least)
Name Relationship Phone #s

Medication Pill size Total daily dosage How often/ When For condition
Put brand name of medication, and generic name Ex- 350 mg Ex. 2 pills daily Ex. One pill with breakfast, one at bedtime Ex. High blood pressure

Medication Allergies (include reactions) _____________________________________________________________________________________________________

Medical conditions:
List all medical conditions/ surgeries (& date) here : ex. High Blood pressure, Asthma, Knee replacement surgery 11/5/99

Physicians: Primary Care Physician: Name & phone # _____________________________________________________________________________________________________
Additional doctors (ex. Optometrist, dentist, orthopedist, cardiologist, etc.)

Pharmacy: Name, address and phone # ______________________________________________________________________________________

Posted by
2788 posts

When taking a RS tour, your package of tour information includes a medical form. I am not sure that one could get it from the Travel Desk but contact them to be sure.

Posted by
143 posts

We carry a similar form with us when we travel, and when we go to Europe, we also carry a rough translation (thanks to Google Translate) in the language of the countries to which we are traveling. In addition, we also carry a copy of our most recent EKG. This proved to come in handy on a recent trip we took when my wife ended up in the emergency room and could show them the forms.