Vial of Life














After using your computer to fill out the Vial of Life form below, click on the PRINT button to print. Let your family and local rescue officials know where you will be keeping this information for easy access in case of an emergency.


Personal Information

Name:
Address:
City:
State:
Zip:
Phone:
Birthdate:
Sex: Male     Female
Social Security #:
Private Insurance:
Medicare #:
Medicaid #:
Family Physician:
Physician Phone:
Specialist:
Specialist Phone:
Hospital Preference:

Medical History

Heart Condition: Yes          No
Pacemaker: Yes          No
High Blood Presure: Yes          No
Normal Reading for person:
BP:
Date:
Diabetes: Yes          No
Controlled By:
Insulin:		 Type
Amount
Time
Pills
Dose
Diet
Glasses: Yes          No
Emphysema: Yes          No
Epilepsy: Yes          No
Asthma: Yes          No
Cancer: Yes          No
Parkinsons': Yes          No
Contacts: Yes          No
Dentures: Yes          No
Arthritis: Yes          No
Thyroid: Yes          No
Memory Problem: Yes          No
Hearing Impairment: Yes          No
Other:
Date of last tetanus shot:
Date:

Medications & Instructions:

Where I keep my medications:

Allergies:

Special Health Problems:

Name of other people in household:

In case of emergency, contact:

Name:
Address:
City:
State:
Zip:
Phone:
Do you have
a living will?		 Yes
No
A durable Power of
Attorney for Health Care?		 Yes
No

If so, who has this information?

Name:
Address:
City:
State:
Zip:

Skilled Nursing Facility Choice:
Hospital Choice:
Home Care Agency is





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