File Of Life Card

    
 
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