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Emergency Medical Information Form
Name ________________________________________ Address ________________________
_____
_________
City _________________________ State_____ Zip Code_______________ Home phone_____________________
Work phone___________________ Cell phone ___________________ Email ______________
_____________
__
Date of Birth__________________ SSN:________________________ (keep this information secure) Blood Type _
____
__
Prior transfusion reaction (describe)__________________________________________________________________
Please check all that apply:
Contact lenses _____ Dentures _____ Diabetic_____ Epileptic_____ Metal in body_____
Additional information: _________________________________________________________________________
Allergies to medications?_____ Please list ____________________________
___________________________
____
List all medical conditions:_______________________________________________________
_____________
___
_____________________________________________________________________
___________
_________
List Dietary Restrictions:_________________________________________________________________________
List all surgeries and hospitalizations:
Year Surgery Performed/Reason for Hospitalization Location
Medicare Beneî‚­ciary? Yes ___ No ___ Medicare Part D? Yes ___ No ___ Medicare # ______
_________
___________
Supplementary/Insurance Company ____________________________________ Phone ______
___
_________
____
Group #___________________________ Policy #___________________________ Attach Copy of Cards
Preferred Hospital: __________________________________________________________________
Primary physician and/or medical treatment facility:
Physician Name __________________________________ Phone _____________
______
__________
Senior Emergency Medical Information Form
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