Here is a helpful list of basic health-related questions we believe one should carry at all times in the event of something happening.  For example, if you or a loved one is rendered incapacitated, someone can refer to this list for immediate action.  Please print a copy or save a digital version for yourself or to share with your loved ones.

For more forms and in-depth questions, you can purchase a download of My Living Legacy here.

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Name (first, middle, last)

See medical directive in wallet (if it applies)

Address (home)

Home phone

Cell phone

Email

Notify person(s)

Condition(s)

Medication(s)

Allergies

Surgeries

Family / Friend names, addresses, contact numbers, and email addresses in case of emergency:

Pharmacy

Hospital

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

(Check here)_______  – OR –  I refuse to make an anatomical gift (Check here)_______

Except

Religious needs

Resuscitate if possible (Check here)_____ – OR – Do not resuscitate (Check here)_____

Signature

Date

(This represents my electronic signature)

Date

 

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