Name:
___________________
Address:
____________________
DOB:
_________
Blood Type:
______
City:
______
_______ ___
State: Zip:
Organ Donor:
Dentures:
Diabetic:
Contacts
:
Metal in Body:
DNR: Living Will:
Epi Pen:
EMERGENCY CONTACT
Name:
_____________________
Phone:
_____________________
PHYSICIAN CONTACT (PRIMARY)
PHYSICIAN CONTACT (SPECIALTY)
Name:
_____________________
Phone:
_____________________
Name:
_____________________
Phone:
_____________________
Specialty:
____________________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
__________
__________
__________
ALLERGIES
(Food, Drug, Latex)
REACTION
MEDICAL CONDITIONS
Diagnosis Doctor Phone #
________________
________________
________________
________________
Pharmacy:
___________________
Phone #:
___________________
MEDICATIONS
Rx Name Dosa How Often Reason
____________________
____________________
____________________
____________________
____________________
Address:
___________________
©2019 ChronicIllnessWarriorLife™
Emergency Medical Information Card (Wallet Size)
Dylan Schmidt
513-780-5147
Dr. Mark Stelly
347-218-9371
Dr. Ryan Williams
521-648-9274
Rheumatologist
Mary Smith
11-13-1972
A Negative
123 Winding River Ln.
Somewhere
AK
12345
Depression
Rheumatoid Arthritis
Ryan Williams
Alex Gonzalez
592-437-1233
713-620-4783
Non-Steroid Anti-Inflammatory Drugs
Air Passageway Closes Up
273-492-2815
CVS
345 Crossing Blvd. Kalamazoo, ID 13573
Singulair
Xeljanz
Zoloft
10 mg
1x/day
5mg
25mg
1x/day
1x/day
Seasonal Allergies
Rheumatoid Arthritis
Depression
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