The small chart to follow allows you to cary your significant medical history and current medication in your wallet or purse. It will allow healthcare providers all the inforamtion that they need about your history. It is simple to fill out. Just fill out your name, date of birth, allergies to medications and advance directives. Then fill in the collumns with the medical conditions, previous surgeries and your currect medications (name, dosage and how many times a day). Cut it out and carry it in your wallet or purse. That's it! This little form can speak for you to healthcare providers. 

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Name                     Date of Birth             Med. Allergies                     Adv. Dir.
 
 
 
 

      Medical                                       Surgical                             Medications
 

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Modified 04/13/02