COUNCIL ON AGING - SOUTHERN CALIFORNIA Medical Emergency Data (In the event of an emergency, call 911) PERSONAL INFORMATION MEDICAL DATA Name: ________________________________________ Address: ______________________________________ Date of Birth: __________________________________ Religion: ______________________________________ Living Will/Trust on file at: _______________________ Advance Health Care Directive on file at: __________ _______________________________________________ Do you have an Advance Health Care Directive or a DNR form? o Yes o No Where is it located? ____________________________ EMERGENCY CONTACTS Name: ________________ Phone: _________________ Address: ______________________________________ Relation: ______________________________________ Name: ________________ Phone: _________________ Address: ______________________________________ Relation: ______________________________________ MEDICAL INSURANCE Insurance Company: ___________________________ Member ID: ___________________________________ Other Med. Ins.: _______________________________ Member ID: ___________________________________ Medicare #: ___________________________________ Medi-CAL #: ___________________________________ Supporting well-being, independence and peace of mind 78 Answers Guide 22/23 714-619-2129 COUNCIL ON AGING - SOUTHERN CALIFORNIA IS A 501 (C)3 NONPROFIT CORPORATION. TO DISTRIBUTE ANSWERS FREE OF COST, WE MUST SELL ADVERTISING SPACE. WHILE WE APPRECIATE THE PAID LISTINGS IN ANSWERS, THEIR INCLUSION DOES NOT IMPLY A RECOMMENDATION OR ENDORSEMENT OF PRODUCTS OR SERVICES BY COASC. ALWAYS BE A VIGILANT CONSUMER. VERIFY INFORMATION AND SEEK REFERENCES WHERE APPROPRIATE. Allergies______________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ® Doctor: _______________ Phone: _________________ Doctor: _______________ Phone: _________________ Blood Type: ___________________________________ Medical Conditions: ____________________________ ______________________________________________ ______________________________________________ Recent Surgeries (include date): _________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ Medications MEDICATIONS Dosage Frequency VALUABLE CHECKLISTS