Vial Of Life

New Jersey Health Care Quality Institute Initiatives
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Vial Of Life

Basic Information
Name
Social security:
Street address:
City:
State:
Zip:
Telephone:
Date of Birth:
Sex: Male Female

Height: Weight:
Hair color: Eye color:
Blood type:  
If Pacemaker, model #: If Defibrator, model #:
Hearing Aid: Left   Right Deaf:   Left     Right
Vision: Glasses: Yes     No
Artificial eye: Left     Right Blind: Left     Right
Native language (if not English):

Medical History
Any identifying marks:
Check conditions you have been treated for in the past:
HIV     Blood pressure     Epilepsey     Heart condition    

Tuberculosis     Anemia     Cancer     Glaucoma     Jaundice    

Arthritis     Diabetes     Hay fever     Sinus    

Asthma     Insulin     Hepatitis     Stroke     Other

Current Medical Information
Currently being treated for:
Current medications:
Dosage:
Frequency:
Located:
   
Current medications:
Dosage:
Frequency:
Located:
   
Current medications:
Dosage:
Frequency:
Located:
   
Current medications:
Dosage:
Frequency:
Located:
   
Name of doctor:
Telephone:
   
Name of doctor:
Telephone:

Last Hospitalization  
Hospital: Location:
Year: Patient #:
Living will: Yes     No Organ donor: Yes    No

Medical Coverage  
Blue Cross #: Blue Shield #:
Medicare #: Medicaid #:
Other: Policy #:

Other Information  
In case of emergency, notify: Relationship:
Street address:  
City: State:
Zip: Telephone:

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