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
Medications:
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 # ______________________________________________________________________________________