Personal Medical Organizer                       Print print www.SeniorARK.com      Seniors meeting the challenges of retirement                                              

**Patient Information**

Patient Name:                                                                                    Birth Date:___/____/_______

Address

Phone: (                                )   Second Phone:  (                              )

Emergency Contact    (Phone/ Name/ Relationship ):  (                               )   

 

Pacemaker, oxygen, hearing aid, other?  List info about any special equipment. Use back if needed.

Drug and Food Allergies: 

 

**Healthcare Professionals Information**

Primary Care Physician:                                       Phone: (                               )   

   Address:

 

Specialist:                                                                Phone: (                              )      

  Address:

 

Specialist:                                                                Phone: (                              )      

  Address:

 

Pharmacy:                                                                Phone: (                             )       

**My Medications**   Include over-the-counter.   Use back of sheet if necessary.

medicine

prescribed by

dosage

when do you take?

were there special instructions?

 

 

 

 

 

 

 

 

 

 

         

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Display this form prominently in your home in case of emergency.   Take one to appointments. 

  

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