Survival Kit - My Health Information
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My Health Information
Name:
Date of Birth: Height:
Sex: M / F Weight:
Blood Type:
Address:
City/ State/Zip:
EMERGENCY CONTACTS
(1) Name:
Phone(s): ( )
Address:
Relationship:
(2) Name:
Phone(s): ( )
Address:
Relationship:
DOCTORS/ PHARMACY
1. Doctor: Phone: ( )
2. Doctor: Phone: ( )
Pharmacy: Phone: ( )
LIVING WILL/ ADVANCE DIRECTIVE
On File At:
Living Will: Yes / No
Durable Power of Attorney: Yes / No
Do Not Resuscitate Form: Yes / No
MEDICAL CONDITIONS
(Check All That Exist)
( ) Angina ( ) Implanted Device
( ) Asthma ( ) Implanted Hardware
( ) Bleeding Disorder ( ) Joint Replacement
( ) Cancer ( ) Liver Disorder
( ) Cataracts ( ) Memory Impaired
( ) Coronary Bypass Graft ( ) Pacemaker
( ) Dementia ( ) Alzheimer’s
( ) Diabetes/Insulin dependent
( ) Renal Failure ( ) Paralysis
( ) Eye Surgery ( ) Hem dialysis
( ) Respiratory Disorder ( ) Seizure Disorder
( ) Hepatitis ( ) Speech Impairment
( ) Hypertension/High BP ( ) Stroke
( ) Hypoglycemia
( ) Other
ALLERGIES
( ) No Known Allergies ( ) Horse Serum
( ) Penicillin ( ) Aspirin
( ) Insect Stings ( ) Sulfa
( ) Barbiturates ( ) Latex ( ) Codeine
( ) Eggs
( ) Tetracycline ( ) Lido Cain
( ) Demerol ( )
Environmental
( ) X-Ray Dyes ( ) Morphine
( ) Novocain
( ) Other Allergies
SURGERY HISTORY (RECENT)
Date:
Date:
Date:
MEDICAL INSURANCE
Medical Insurance Company:
Policy #:
Other Medical Insurance.
Policy #:
Medicaid #:
Medicare #:
CURRENT MEDICATIONS
Drug Name Dose Doctor/Pharmacy Phone
Notes:
Include a recent photo of you and your dog for identification in case you are separated.
Store paperwork in a water tight plastic bag and/or water tight plastic container.