File of Life Page

Town of Orient

FILE OF LIFE Page

A major project for 2005 was to provide and deliver to each Orient resident and regular visitor who has reached his 60th birthday or who may have a medical issue...

a personal FILE OF LIFE packet.

The purpose of each of these packets is to help make vital medical information readily available to emergency responders at a time of certain need. Each recipient completes a form with his own personal data and medical information, places that data sheet in a red plastic magnetized holder and attaches that holder to the front of the residence's refrigerator...a place that emergency medical responders know to look.

Additional data sheets and holders (for all residents of and regular visitors to the Town of Orient) are available to be picked up at the Orient Town Hall, courtesy of the members of The Grand Association. Anyone may obtain a File of Life packet for their own use.

You need not be age 60 or in need of a packet for medical reasons to obtain one. They are free. If more are needed, TGA will purchase more sets.

As an alternative, you may print this web page, complete the information and attach this form to the front of your refrigerator.

FILE OF LIFE EMERGENCY MEDICAL DATA:
Review this information EVERY SIX MONTHS. Keep it up to date !
USE PENCIL for ease in making changes.

Last Reviewed on ________________200___

THE DATA ON THIS FORM IS FOR:
My NAME:
I am Male - Female
My Residence Address:
My Residence Phone:
My Date of Birth:
My Soc. Sec. No.:
My Blood Type:
My Religion:

My PERSONAL PHYSICIAN is:
Address:
Office Phone:
My OTHER DOCTOR is:
Address:
Office Phone:

EMERGENCY CONTACTS:
FIRST CONTACT'S NAME is:
Relationship:
Address:
Phone:
SECOND CONTACT'S NAME is:
Relationship:
Address:
Phone:

MY PERSONAL MEDICAL DATA:
Comments and Remarks about my Special Medical Conditions:

This is a LIST of MY:
Medical Problems: Medication: Dosage: Frequency per Day:
Example: Hypertension - Toprol - 50mg - Once a day - Example only!
1)
2)
3)
4)
5)
6)
7)
8)
9)

My PRESCRIPTIONS are on file at:
Pharmacy Name:
Address:
Phone:

My "Health Care Proxy" is ___________________(or NONE)
The Documentation is located:

My original "Living Will" is located:_________________(or NONE)
A copy is located:

I DO DO NOT have a "No Cardio-Pulmonary Resusitation" Directive.
A copy is located:

I DO DO NOT have a "Do NOT Resusitate" Directive.
A copy is located:

I have had the following SURGERY in the last FIVE (5) YEARS: Describe and Give dates:
1)
2)
3)
4)
5)

I have the following MEDICAL CONDITIONS:
Check ( OR X ) all that apply.
( ) I have No Known Medical Conditions !

BLOOD CONDITIONS:
( ) Abnormal EKG ( ) Angina ( ) Hypertension
( ) Cardiac Dysrhythmia ( ) Coronary Bypass Graft
( ) Heart Valve Prosthesis ( ) Pacemaker
( ) Bleeding Disorder ( ) Clotting Disorder ( ) Hemolytic Anemia
( ) Hypoglycemia ( ) Diabetes ( ) I am Insulin Dependent
( ) Leukemia ( ) Sickle Cell Anemia
( ) Other Heart or Blood Disorders: LIST!

BRAIN CONDITIONS:
( ) Dementia ( ) Alzheimer's Disease
( ) Memory Impaired ( ) Seizure Disorder
( ) Stroke ( ) Other Mental Disorders: LIST!

BREATHING CONDITIONS:
( ) Asthma ( ) Emphysema
( ) Other Breathing Disorders: LIST!

OTHER MEDICAL CONDITIONS:
( ) Adrenal Insufficiency ( ) Myasthenia Gravis
( ) Recent Eye Surgery ( ) Glaucoma ( ) Cataracts ( ) Vision Impaired
( ) I am Hearing Impaired
( ) I have a Speech Impediment ( ) Laryngectomy
( ) Lymphoma ( ) Other Active Cancer:
( ) Renal Failure ( ) Hemodialysis
( ) Other:
( ) Other:
( ) Other

ALLERGIES: Check ( OR X ) all that apply.

( ) I have No Known Allergies

CHEMICAL ALLERGIES:
( ) Aspirin ( ) Barbiturate ( ) Codeine ( ) Demerol
( ) Horse Serum ( ) Lidocaine ( ) Morphine ( ) Novocaine
( ) Penicillin ( ) Sulfa Drugs ( ) Tetracycline
( ) X-Ray Dyes ( ) Other Chemical Allergies: LIST!
ENVIRONMENTAL ALLERGIES:
( ) Latex
( ) Insect Stings
( ) Nuts ( ) Eggs ( ) Seafood ( ) Wheat/Glutin ( ) Lactose ( ) Soy
( ) Other Environmental Allergies: LIST!

About MY MEDICAL INSURANCE:
Primary Medical Insurance Company:
Policy #:
Group #:
Phone:
Other Medical Insurance Co:
Policy #:
Group #:
Phone:
Medicare #:
Medicaid #:

Revised: March 16, 2010.

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