“The simple form that could save your life” is what writer Seth Godin calls this document that provides all of your basic medical information in one spot. It won’t take you long to fill out, and it’s easy to update. You can print it out and take it with you every time you visit a doctor. You can give it to your spouse/partner and your kids so they won’t have to guess about any of this if they’re helping you in an emergency. You can keep a printed version for yourself somewhere that’s easy to access.
And, as Seth suggests, forward a blank form or this post to people who will benefit from having it.
CONFIDENTIAL AND DETAILED HEALTH INFORMATION [date]
[You can download the doc file from Seth’s post, or select and copy this list to your word processor, then edit it. Throughout this form, fill out the information between the brackets, and then delete the instructions]
CONTACT INFORMATION
[name]
[address]
[home phone]
[cell phone]
[social security #]
[spouse/partner’s name]
[in case of emergency contact info]
PRIMARY CARE PHYSICIAN
[name, phone, affiliated hospitals]
INSURANCE
[name of provider; contact info; GROUP, if applicable]
CURRENT MEDICATIONS
[drug name, one by one, including dosage and frequency; purpose; and when first prescribed — approximately is fine]
ALLERGIC REACTIONS
CHRONIC ILLNESSES
[diabetes, arthritis, etc.]
PREVIOUS ILLNESSES
[in reverse chronological order, most recent first]
PREVIOUS SURGERIES/ACCIDENTS
[if you can, include names and contact info of previous doctors/hospitals]
FAMILY HISTORY
[brief statement for each family member, including grandparents, parents and siblings; include ages, serious illnesses and/or cause of death]
SOCIAL HISTORY
[alcohol, smoking, drug use]
LIFESTYLE
[exercise, diet]
ADMINISTRATION
[details about advanced directive, living will, health care proxy, name, phone and fax number of your pharmacy, organ donor status]
