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FOR EMERGENCY CALL 911

The File of Life program is sponsored by the
Boone County Hospital Foundation
Name:
Sex:
M / F
Address:Date of Birth:
Doctors:Phone #:
Doctors:Phone #
MEDICATION DATA
List all current Medications, Vitamins, Herbs, and Supplements.
A complete and up-to-date list of all the medications (prescriptions and over-the-counter), vitamins, herbs, and supplements you take is essential information your healthcare providers need to provide you with safe and accurate health care. Keep this list with you for every healthcare visit; take it with you to the doctor and to the hospital. Update every time you see your doctor. Use pencil for ease in making changes
Medications/Vitamins
Herbs/Supplements
Date Started
Dosage
Frequency
EMERGENCY CONTACT:
Name:
Address:
Home Phone #: Work Phone#:
Do you have any of the following:
1. Out-of-Hospital
Do Not Resuscitate (OOHDNR) Directive?Yes No
2. Advanced Directives/Living Will?Yes No
3. Power of Attorney (POA) for Healthcare?
Name of POA: Yes No
MEDICAL CONDITIONS Check all that exist
No known medical condition Glaucoma
Adrenal insufficiency Heart Attack
Anemia Heart Valve Prosthesis
Arthritis Hepatitis
Asthma HIV
Bleeding/Clotting Disorder Hypertension
Cancer/Leukemia/lymphoma Hypoglycemia
CHF Osteoporosis
COPD/Emphysema Pacemaker/AID (defibrillator)
Coronary Bypass Graft Parkinson’s
Dementia Renal Failure
Diabetes Seizure Disorder
Dialysis Stroke
GERD or Reflux Disease
Surgeries-Please List Implants-Please List:
ALLERGIES
Latex
Others:
VACCINATIONS
Pneumonia Date:Others:
Flu Date:
Tetanus Date:
Please Copy both sides of your Health Insurance and/or Medicare/Medicaid card and Attach the Copy to this form.
This form may also be obtained from the Boone County Hospital Website at www.boonehospital.com
QUICK INFO
1015 Union Street
Boone, IA 50036
(515) 432-3140

To download the PDF of the File of LIfe medication List.

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1015 Union Street | Boone, IA 50036 | Phone: (515) 432-3140 | Fax: (515) 433-8926


Select photos courtesy of Courtney Davidson