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.
Name (first, middle, last)
See medical directive in wallet (if it applies)
Address (home)
Home phone
Cell phone
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