MEDICAL INFORMATION

NOTE: You can fill out this form online and print it, or print it, then fill it in by hand. You may want to print extra copies, as the information you enter will NOT be saved once the window is closed. This is to protect your privacy. Print one for each family member, store in a handy place AND make sure you update it regularly.

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NAME:

ADDRESS:

PHONE (HOME):

PHONE (WORK):

DATE OF BIRTH:

INSURANCE:

GROUP/POLICY #:

PERSON TO CONTACT:

RELATIONSHIP:

HIS/HER PHONE NUMBER (HOME):

HIS/HER PHONE NUMBER (WORK):

LAST UPDATED:

KNOWN MEDICAL PROBLEMS

Seizures?

Heart?

Diabetes?

Lung?

Cancer?

Stroke?

Blood Pressure?

Hepatitis?

HIV/AIDS?

IF YES TO ANY, TYPE SPECIFICS

Other?

Other?

Other?

Other?

ANY KNOWN ALLERGIES:

CURRENT MEDICATIONS (PRESCRIPTION & OTC) / DOSAGE / WHERE STORED

ADDITIONAL INFORMATION