{this form is available at the Town Office}

Name:                                                                                   Sex: M / F
Address:
Date of Birth: 

EMERGENCY CONTACTS

 
Name #1:                                                                    Home Phone:
Address:
Relation:                                                                      Work Phone:
 
Name #2:                                                                     Home Phone:
Address:
Relation:                                                                       Work Phone:                                                             

 

MEDICAL DATA

 
Last Updated: Month                     Year:                                    Blood Type:
Doctor:                                           Hospital:                              Phone Number:
Doctor:                                           Hospital:                              Phone Number:

 

Special Conditions / Remarks: _______________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

 
Medical Problems: Medication: Dosage: Frequency:
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
Recent Surgery:                                                                                                        Date:
 
 
 
 

 
Religion:
Living Will on file at:
Health Care Proxy on file at:

 

Do you have an EMS-NO CPR Directive or a DNR Form?

YES ____                              NO _____

 

MEDICAL CONDITIONS

Check all that exist

___ No known medical conditions                                      ____Hemodialysis

___Abnormal EKG                                                          ____Hemolytic-Anemia

___Adrenal Insufficiency                                                 ____Hepatitis Type (     )

___Angina                                                                             ____Hypertension

___Asthma                                                                            ____Hypoglycemia

___Bleeding Disorder                                                           ____Laryngectomy

___Cancer                                                                             ____Leukemia

___Cardiac Dysrhythmia                                                      ____Lymphomas

___Cataracts                                                                         ____Memory Impaired

___Clotting Disorder                                                            ____Myasthenia Gravis

___Coronary Bybass Graft                                                   ____Pacemaker

___Demential /Alzheimer’s ____                                         ____Renal Failure

___Diabetes / Insulin Dependent                                          ____Seizure Disorder

___Eye Surgery                                                                     ____Sickle Cell Anemia

___Glaucoma                                                                         ____Stroke

___Hearing Impaired                                                             ____Tuberculosis

___Heart Valve Prosthesis                                                     ____Vision Impaired

___Other:_________________________________________________________

ALLERGIES

___Aspirin                   ___Insect Stings           ____Penicillin              ____Food Allergies

___Barbiturate             ___Latex                      ____Sulfa                      ____Seafood

___Codeine                  ___Lidocaine               ____Tetracycline          ____Peanuts/Nuts

___Demerol                 ___Morphine                ____X-Rays Dyes

___Horse Serum          ___Novacaine               ____No Known Allergies

___Environmental: ____________________________________________

___Other:____________________________________________________

MEDICAL INSURANCE

Medical Insurance Company:____________________ Phone #:___________________

Policy #:____________________________________

Medicare / Medicaid #: ________________________ Other Insurance:_____________