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medical history

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Health information (basic)

Name (first, middle, last)) --------------------------------------------------------------------------------

See medical directive in wallet (if it applies)

Address (home) ------------------------------------------------------------------------------------------------

Home phone--------------------------------- Cell phone-------------------Email---------------------------

Notify / person(s) ---------------------------------------------------------------------------------------------

Illness (s) ----------------------------------------------------------------------------------------------------

Medication (s) current---------------------------------------------------------------------------------------

Allergies ------------------------------------------------------------------------------------------------------

Surgeries -----------------------------------------------------------------------------------------------------

Family (s) names, addresses, contact numbers, and email address. ----------------------------------------

--------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------------

Friend (s) names, addressed, contact numbers, and email addresses---------------------------------------

--------------------------------------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------------------------------

Pharmacy ----------------------------------------------------------------------------------------------------

Hospital /other ----------------------------------------------------------------------------------------

Anatomical Gift Statement Upon my death I wish to donate All organs, tissues or eyes

(Check Here)--- I refuse to make an anatomical gift (Check Here)--- ---

Except ------ ------------------------- Religious needs-------------------------------------------------

Signature –----------------------------------------------------------------------------------------------- Date--------------------------

(This represents my electronic signature).---------------------------- Date—------------------------

Resuscitate if possible Check here---- Do not resuscitate Check here----

 

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