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EMERGENCY MEDICAL DATA
ORDER OF CARMELITES
Name
*
First Name
Last Name
Email
*
Phone Number
*
Cell phone preferred
Format: (000) 000-0000.
Birthdate
*
-
Month
-
Day
Year
Age
*
Height
*
Weight
*
Eye Color
*
Hair Color
*
Identifying Marks
Social Security Number
Medicare Number
Primary Insurer
Policy Number
Phone
Supplementary Insurer
Policy Number
Phone
Your Doctor's Name
First Name
Last Name
Doctor's Phone Number
*
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Alternate Doctor
Doctor's Phone Number
Format: (000) 000-0000.
Hospital Preference
City
Have you filled out a Durable Power of Attorney for Health Care form or a Living Will form?
Yes
No
Are copies on file at Provincial Office (630) 971-0050?
Yes
No
Emergency Contact Name
Relationship
Cell Phone
Home Phone
Emergency Contact Name
Relationship
Cell Phone
Home Phone
Emergency Contact Name
*
Relationship
*
Cell Phone
*
Home Phone
Medication (Please indicate what medication(s), dosage and frequency, if none enter NA)
*
Inoculations (if none enter NA)
*
Drug Allergies (if none enter NA)
*
Food Allergies (if none enter NA)
*
Any past complications w/ anesthesia?
If yes, pleases describe.
Health Status (check all that apply)
Heart problems
High blood pressure
Heart attack
Alzheimer's
Stroke
Cancer
Diabetes
Parkinson's
Prostate
Other
Do you wear:
Contact Lenses
Glasses
Dentures/Bridges/Caps
Hearing Aid(s)
Use a cane or walker
Use Oxygen
Other
Past Surgeries (if none enter NA)
*
Organ Donor
Yes
No
Some
Other/Explain
Funeral Arrangements on File?
Yes
No
If YES specify entity phone number
Do you have pets?
Yes
No
Type and name of pet
Pet location and special info:
Location of leash/meds/toys/vet paperwork, etc.
Who should be called to care for your pet?
*
Date Completed
*
-
Month
-
Day
Year
Date
Person completing form (if other than name on form)
Name / Phone
Other pertinent information:
Submit
Should be Empty: