VIAL Of LIFE INFORMATION - My Precious Kid®

Complete the FREE form then print from your computer
Instructions / Form / Labels

PERSONAL INFORMATION

Name: Primary Language
Address:
Male: Female: Birth date
Location of Living Will or DNR
Insurance Name/Phone
Doctors Name/Phone
Medicare # Insurance#

MEDICAL HISTORY
AIDS Anemia Breathing problems Cancer Diabetes Emphysema
Epilepsy Eye problems Heart condition Hearing problem Hemophilia
High Blood Pressure Hypoglycemia Low Blood PressurePacemaker
Seizures Stroke Other
Your normal Blood Pressure
MEDICATIONS AND DOSAGES


Where are medications kept: ALLERGIES:
Other special health information:

Hospital preference:

EMERGENCY CONTACTS
Name/Phone to call if you are ill/injured:
Name/Phone to call if you are ill/injured:
Name/Phone to call if you are ill/injured:

I authorize medical care for myself and my family in the event of injury or illness. I certify this form is accurate and up to date. I understand emergency personnel may rely on this and agree to hold the user harmless.

Name: ___________________________Date: ______________________

Keep this form UP-TO-DATE. Use the back of the form for additional information.

• Fill out the form including date completed and PRINT
• Include a PHOTO ID card for identification
• Fold and place all inside an empty pill bottle.
• Place VIAL of LIFE logo on outside of bottle
• Place bottle in refrigerator under top shelf with tape or rubber band
• Tape Logo on Refrigerator

• Tape Logo on front window pain

Explanation of Vial of Life form:

A Living Will and a Do Not Resuscitate (DNR) order are legal documents that allow a person to pre-determine the type of care they wish to receive in the event of a sudden or chronic terminal condition. These forms are available at all physician’s officers. A DNR order allows the patient to decide if they want CPR if they should go into cardiac arrest and allows the patient to decide if they want a breathing tube inserted into their airway if they should develop a severe respiratory problem. Most patients that have these forms keep them with their important papers. In order for emergency personnel to honor the patient’s wishes, these forms MUST be accessible at the time of the emergency.

Normal Blood Pressure: is the average blood pressure that is normal for you after being taken three times.
Medications and Dosages: Names of medications are most important, dosage is helpful information. We are unable to identify by sight, you must name them.
Where are Medications Kept: For example: the kitchen cabinet by the microwave, the medicine cabinet in the hall bath, or on the dresser in the master bedroom.
Allergies: We need to know if you are allergic to any medicine at all.
Hospital Preference: We try to comply with your wishes, however, at times we may have to transport you to an alternate hospital.
Person or persons to call if you are ill/injured: We refer to this as “emergency contacts”.
Other special health information: Past surgeries, special needs.