Name: ____________________________________
Address: __________________________________
__________________________________________
__________________________________________
__________________________________________
Telephone: _________________________________
__________________________________________
Emergency Contact: __________________________
__________________________________________
__________________________________________
__________________________________________
Allergies: __________________________________
__________________________________________
__________________________________________
Past Illnesses or Operations: ___________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Doctors' Names and Phone Number(s): ___________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Medical Insurance Company and Number(s): _______
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Return to Prevention Charts
Pocket Guide to Staying Healthy at 50+