Emergency Medical Information

Name:

Birthdate:
Height: ft. in.
Weight: lbs.

Medical Insurance:

Group number / personal ID number:

Durable Power of Attorney for Health Care:

Contact Information for Durable Power of Attorney:

Living Will?   Yes   /   No

Location of Living Will:

Primary Physician:

Phone:

Other Physician #1:

Phone:

Other Physician #2:

Phone:

Other Physician #3:

Phone:

Special instructions for medical situations:

Primary Disability:

Secondary Disability:

Special instructions regarding my disability:

Drug Allergies:

Other Allergies:

Special instructions regarding my allergies:

Prescription Medications:

Over-the-Counter Drugs and Supplements:

Special instructions regarding my medications and supplements:

Dietary Requirements:

Dietary Restrictions:

Recent Hospitalizations or Illnesses:

Notes regarding special equipment and/or home arrangements:

This information was updated on:

Tools > Personal Assistant Evaluation Form

This tool is part of InfoUse's Working Together, a website for consumers of personal assistance services. http://www.infouse.com/pas/.

Copyright © 2000-2001 InfoUse Email. All Rights Reserved.