File Of Life Card

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

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:

Latex
Others:

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