Vial Of Life

Initiatives > Vial Of Life

Basic Information
First Name
Middle Name
Last Name
Social security:
Street address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
Date of Birth:	Format should be Year, Month, Day (April 18, 1970 should be 70/04/18)
Sex:	Male Female

If Pacemaker, model #:	If Defibrator, model #:
Blind: Left Right	Deaf: Left Right
Vision:	Glasses: Yes No
Artificial eye: Left Right	Contacts: Yes No
Hearing Aid: Left Right
Prosthetic Devices:
Native language (if not English):

Medical History
Any identifying marks:
Check conditions you have been treated for in the past:
HIV Blood pressure Epilepsey Heart condition High Cholesterol Tuberculosis Anemia Cancer Glaucoma Jaundice Arthritis Diabetes Hay fever Sinus Obesity Asthma Insulin Hepatitis Stroke Chronic Pain Depression Other
List condition and timeframe for any items checked above:

Current Medical Information
Currently being treated for:
Please list all current medications:
Medication/Non Prescription:
Dosage:
Frequency:
Located:

Medication/Non Prescription:
Dosage:
Frequency:
Located:

Medication/Non Prescription:
Dosage:
Frequency:
Located:

Medication/Non Prescription:
Dosage:
Frequency:
Located:

Any additional medications:

Physicians Please list all doctors, specialty area (general practitioner, dermatologist) and phone numbers:

Are you allergic or have you had a reaction to any of the following:

Local Anesthesia Codeine or Narcotics Penicillin

Aspirin Sulfur/Other Antibiotics Sleeping Pills

Barbiturates/Sedatives Iodine Latex

I/V Dyes Food Seasonal Insect Bites

Please list any other allergies you may have:

Pregnancy History
Have you ever been pregnant? Yes No
Any complications with any pregnancy/child birth? Yes No
If yes, explain:
Have you given birth to any children with birth defects? Yes No
If yes, explain:
How many births have you had?

Last Hospitalization
Hospital:	Location:
Patient #:	Year:
Diagnoses:
Do you have a Living Will? Yes No
If yes, where is it stored:
Have you agreed to be a organ donor? Yes No

Surgical Procedures Check off all surgeries you have had and list years if possible:
Procedure	Year	Please explain details
Appendectomy
Tonsillectomy
Prostate
Hernia
Orthopedic Procedures
Bariatric (obesity) Surgery
Cataract
C-Section
Back
Hysterectomy
Heart Surgery
Gall Bladder
D&C or Other
Neck
Any Tranplants

In case of an emergency notify:
Contact #1
Name:		Relationship:
Home Phone:		Cell Phone:

Contact #2
Name:		Relationship:
Home Phone:		Cell Phone:

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