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Date Completed ____________
EMERGENCY INFORMATION
NAME: __________________________________________________________________ DOB: ____________________
Emergency Contacts Family Contact - Name: ______________________________ Home Phone: _______________ Work Phone: _____________
Address: ___________________________________________________ Relationship: __________________________________
Parish Contact - Name: ______________________________ Home Phone: _______________ Work Phone: _____________
Address: ___________________________________________________ Relationship: _________________________________
Deanery Contact - Dean: ______________________________ Home Phone: _______________ Work Phone: ____________
Diocese Contacts – Vicar General:
Medical Data Last Updated - Month: ____________ Year: ____________ Blood Type: ____________
Primary Physician – Name: ______________________ Phone: ____________ Office Address: __________________________
Other Physicians – Name: _______________________ Phone: ____________ Speciality: _____________________________
Name: _______________________ Phone: ____________ Speciality: _____________________________
Special Medical Conditions/Remarks Medication Dosage Frequency Medication Dosage Frequency
Medical Conditions – Allergies: ________________________________________________________________________________
Medication Allergies: ________________________________________________________________________________________
Med. Ins. Company: ________________________________________________ Policy Number: _________________________
Other Med. Ins. Company: ___________________________________________ Policy Number: _________________________
Medicaid Number: ____________________________________ Medicare Number: ____________________________________
Living Will on file at: ________________________________________________________________________________________
Health Care Proxy Name: ___________________________ Phone: _______________ On File At: ______________________
Organ Donor: YES NO
Medical Conditions – Check All That Exist No known medical conditions Abnormal EKG Adrenal Insufficiency Angina Asthma Bleeding Disorder Cardiac Dysrhythmia Cataracts Clotting Disorder Coronary Bypass Graft Dementia Alzheimer’s Diabetes/Insulin Dependent Eye Surgery Glaucoma Hearing Impaired Hemodialysis Hemolytic Anemia Hypertension Hypoglycemia Laryngectomy Leukemia Lymphomas Malignant Hypothermia Memory Impaired Myasthenia Gravis Pacemaker Renal Failure Seizure Disorder Sickle Cell Anemia Stroke Vision Impaired Other Implanted Defibrillator
(Return original to Office of the Bishop, give copy to your Dean and keep a personal copy where it can be easily accessed.) Rev. May 2016