MEDICAL INFORMATION
Name: ................................................................Date:..............
Prefered Hospital:....................................................................
In Emerg. notify:............................................Tele.#(.....)............
I am under treatment for:
Diabetes.......... High Blood Press.......... Heart Cond.......... Stroke..........
Other........................................BLOOD TYPE............
Medicare Number:.....-....-.......................
Other Ins.Co............................. ID#.......................
Primary Doctor:.......................... Phone:(...)...............
Specialist:............................... Phone:(...)...............
Specialist:............................... Phone:(...)...............
Prescription Medications that I am CURRENTLY taking:
NAME Of Prescription DOSAGE TAKEN HOW OFTEN ? NOTES
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Over the Counter Medications I am Taking
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Allergic Reactions to:(Medications, food and symptoms)
Special Notes, (Ailments etc.):