# Your Full Name - Medical Reference # Patient Info Full Name (Nickname) Birthdate Social Security Number (if you’re comfortable with this) Home Address Mailing Address Phone(s) Email Sex / Gender Height Weight Blood type # Primary Contacts Spouse contact (Name, Phone, Email) Contact info for anyone you want access to your health information In case of incapacitation, list HCPOA, POA, Living Will, etc # Health Care contacts ### Primary Care Physician Doctor Name Medical group Address Phone Fax ### Specialists Doctor Name Medical group Address Phone Fax etc # Health insurance ### Primary Insurance Name Primary holder name Group # Member ID Issue date Copay Phone numbers Address for claims (incl payor ID) ### Secondary same as above ### RX etc # Allergies List your allergies and what happens to you. (incl things like latex that you might come into contact with in a medical setting) # Medications ### Prescriptions List medications here, including the generic and name brand, dosage, how often you take it, and for what reason. KEEP THIS UPDATED. It’s best to keep track of medications in only one place, so let’s make it this one as it’s the most critical in an emergency. Also list your preferred pharmacy, including address, phone, and fax. List your RX insurance or discount programs, even if you have it above. ### Regular OTC meds and supplements List any over-the-counter medicines you regularly use (eg, ibuprofen, decongestant, etc) as well as any supplements you take regularly. # Health Conditions List any health conditions you currently have, or major ones you’ve had in the past. # Lifestyle/Substance Use Occupation Alcohol/Tobacco/Marijuana/Recreational Drug use # Surgical History List any surgeries you had here and when each was # Family History If you know of family health issues, list them here with who had them. # Immunizations Add your immunizations here. Include type and date for each.