File of life form

Help is a phone call away….
Emergency Call 911
Police – Fire – Medical
        
   
Use pencil to ease making changes
KEEP INFORMATION UP TO DATE
_______________________________________________________
Name:                                                                               Sex:  M   F
Address:                                                                  Date of Birth:    /      /
Own Guardian?     (circle one)   YES     NO     (if NO, fill in below)
Guardian Name:                                                 Home Phone #:
Address:                                                              Work Phone #:
Guardianship Status (full, limited, etc.):
EMERGENCY CONTACTS (1st responders, use these contacts)
Name:                                                                Home Phone #:
Address:
Relation:                                                            Work Phone #:
ALARM COMPANY
Phone # / Pass Code for Alarm Company:
“POINT OF SAFETY”
Identify the safe place outside your home you would go in case of a fire 
(e.g.; neighbors driveway, tree at end of block, mailbox, etc.)?:
COMMUNICATION  (“X” all areas that apply)
(  ) Verbal   language:____________
(  ) Non-Verbal
(  ) Uses Sign Language
(  ) Uses Communication Device(s)
MEDICAL DATA
Last Updated:  Mo        Year                Blood Type:
Doctor:                                                            Phone #:
Doctor:                                                            Phone #:
Special Conditions / Remarks:
VITALS
DATE
BP
HR
RESP
BGL
TEMP
Your
Photo
Here

Medications
Recent Surgeries
Date
Religion:
Living Will on file at:
Health Care Proxy on file at:
Do you have a DNR/MOLST?        YES        NO  
Where is it located?
MEDICAL CONDITIONS  (check all that exist)
(  ) No known medical conditions     (  ) Abnormal EKG     (  ) Angina
(  ) Adrenal Insufficiency     (  ) Asthma     (  ) Bleeding Disorder
(  ) Cardiac Dysrhythmia     (  ) Cataracts     (  ) Clotting Disorder
(  ) Coronary Bypass Graft     (  ) Dementia     (  ) Alzheimer’s
(  ) Diabetes/Insulin Dependent     (  ) Eye Surgery     (  ) Glaucoma
(  ) Heart Valve Prosthesis     (  ) Hemodialysis     (  ) Hemolytic Anemia
(  ) Hypertension     (  ) Hypoglycemia     (  ) Laryngectomy (  ) Leukemia
(  ) Lymphomas     (  ) Malignant Hypothermia     (  ) Memory Impaired
(  ) Myasthenia Gravis     (  ) Pacemaker     (  ) Renal Failure
(  ) Seizure Disorder     (  ) Sickle Cell Anemia     (  ) Stroke
(  ) Hearing Impaired     (  ) Vision Impaired     (  ) Blind     (  ) Deaf
(  ) Other ____________________________________________________
ALLERGIES (medication, food, other…)
MEDICAL INSURANCE
Med Ins Company:
Policy #:
Other Med Ins Company:
Policy #:
Medicaid #:                                    Medicare #:
PERSONAL CARE  (“X” the areas where you need help)
(  ) Dressing and Undressing
(  ) Chewing and Swallowing
(  ) Bathing or Showering
(  ) Mobility
(  ) Grooming / Personal Care
(  ) Transferring (e.g.; bed to chair, etc.)
(  ) Using the Toilet
(  ) Taking Medications
(  ) Eating
(  ) Using the Telephone