Patient Information
- Full Name: _________________________ Date of Birth: //____
- Preferred Name: _____________________ Social Security #: XXX-XX-____
- Home Address: _______________________ Phone: (__) -
- Living Situation: □ Independent □ Assisted Living □ Nursing Facility □ With Family
Primary Emergency Contacts
Contact 1
- Name: ______________________________ Relationship: _____________
- Phone (Primary): () - Phone (Alt): () -
- Has Medical Power of Attorney? □ Yes □ No
Contact 2
- Name: ______________________________ Relationship: _____________
- Phone (Primary): () - Phone (Alt): () -
- Has Medical Power of Attorney? □ Yes □ No
Healthcare Providers
Primary Care Physician
- Name: ______________________________ Phone: (__) -
- Practice Name: _______________________ Fax: (__) -
Specialists (if applicable)
- Specialty: __________________________ Phone: (__) -
Doctor Name: _______________________
- Specialty: __________________________ Phone: (__) -
Doctor Name: _______________________
Medical Information
- Preferred Hospital: ___________________
- Advanced Directives in Place? □ Yes □ No
- DNR Order? □ Yes □ No
- Allergies: __________________________
- Blood Type (if known): _______________
Medical Device Information
□ Pacemaker □ Hearing Aid □ Prosthesis □ Other: _________________
Insurance Information
- Medicare #: _________________________
- Secondary Insurance: _________________
- Policy #: ___________________________
Signature
Patient/Legal Representative: ___________________ Date: //____
Please update this form annually or when information changes