NAME_________________________ Date of Birth__________ Height_____Weight_______

Daily Medications and Vitamins (name, dosage, prescribed by which doctor and for what purpose)

Medications:

Name_____________Dosage_________Physician______________Condition___________

Name_____________Dosage_________Physician______________Condition___________

Name_____________Dosage_________Physician______________Condition___________

Name_____________Dosage_________Physician______________Condition___________

Name_____________Dosage_________Physician______________Condition___________

Name_____________Dosage_________Physician______________Condition___________

Vitamins/Supplements: (brand/brands) __________________________________________

Name________________Dosage____________Reason for taking_____________________

Name________________Dosage____________Reason for taking_____________________

Name________________Dosage____________Reason for taking_____________________

Name________________Dosage____________ Reason for taking____________________

Name________________Dosage____________ Reason for taking____________________

Name________________Dosage____________ Reason for taking____________________

Pharmacy: Name________________________Phone(        )_________________________

Allergies, adverse reactions to any previous medication or supplement:

Person to contact in case of emergency:

Name____________________________Phone: home _____________other_____________

Address___________________________Relation to me_____________________________

Primary Care Physician:

Name______________________________________________________________________

Address____________________________________________________________________

Phone (       )_______________________

Specialists:

Name________________________Address______________________Phone_____________

Name________________________Address______________________Phone_____________

Name________________________Address______________________Phone_____________

Name________________________Address______________________Phone_____________

Currently being treated for:



Insurance information:__________________________________________________________

Blood type:_______________Cholesterol______________Blood pressure________________

(usual) Hospital preference______________________________________________________

Additional pertinent information__________________________________________________