Medical Information Template
1. Personal Information
Full Name:
Date of Birth:
Emergency Contact Name and Number:
Family Doctor’s Name and Number:
2. Medications
(List all prescriptions, over-the-counter medications, vitamins, and supplements)
| Medication Name |
Dose (mg or units) |
How Often |
Reason for Taking |
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3. Allergies
| Allergen (medication, food, latex, etc.) |
Reaction (rash, anaphylaxis, etc.) |
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4. Diagnoses (Current and Past Medical Conditions)
| Condition/Disease |
Date Diagnosed |
Notes (controlled, in treatment, etc.) |
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5. Surgeries and Procedures
| Surgery/Procedure |
Date |
Hospital/Clinic |
Notes (complications, follow-up) |
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6. Hospitalizations
| Reason for Hospitalization |
Date(s) |
Hospital Name |
Notes |
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7. Vaccination Record (Optional but Helpful)
| Vaccine |
Date |
Notes (e.g., boosters needed) |
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8. Assistive Devices or Supports (if applicable)