Vial Of Life Form
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1North Lyon County Fire Protection District
195 East Main Street
9-1-1
DIAL
Fernley, Nevada 89408
District Office (775) 575-3310
District Fax (775) 575-3314
FOR ALL
EMERGENGIES
VIAL OF LIFE
Date Completed:
__________________
EMERGENCY MEDICAL INFORMATION
FIRST NAME
INITIAL
LAST NAME
SOCIAL SECURITY NUMBER
STREET
CITY
STATE
ZIP
TELEPHONE
DATE OF BIRTH
MALE/FEMALE
HEIGHT
WEIGHT
HAIR COLOR
EYE COLOR
BLOOD TYPE
RELIGION
IF PACEMAKER, MODEL #
DEFIBRILATOR, MODEL #
HEARING AID
DEAF
DENTURES
UNABLE TO SPEAK
L
R
L
R
UPPER LOWER
VISION
GLASSES
CONTACTS
BLIND
ARTIFICIAL EYE
NATIVE LANGUAGE IF NOT ENGLISH
L
R
L
R
IDENTIFYING MARKS
CIRCLE CONDITIONS YOU HAVE BEEN TREATED FOR IN THE PAST
AIDS
BLOOD PRESSURE
EPILEPSY
HEART CONDITION
TUBERCULOSIS ANEMIA
CANCER
GLAUCOMA
JAUNDICE
ARTHRITIS
DIABETES
HAY FEVER
SINUS
ASTHMA
INSULIN Y / N
HEPATITIS
STROKE
OTHER:
CURRENTLY BEING TREATED FOR?
CURRENT MEDICATIONS/DOSAGE/FREQUENCY/LOCATED
CURRENT MEDICATIONS/DOSAGE/FREQUENCY/LOCATED
NAME OF DOCTOR
TELEPHONE NUMBER
NAME OF DOCTOR
TELEPHONE NUMBER
NAME OF DOCTOR
TELEPHONE NUMBER
NAME OF DOCTOR
TELEPHONE NUMBER
ALLERGIES TO MEDICATIONS
LAST HOSPITALIZATION
HOSPITAL
LOCATION
YEAR
PATIENT #
LIVING WILL
ORGAN DONER
REFER TO:
REFER TO:
MEDICAL COVERAGE
MEDICARE #______________________________
MEDICAID #______________________________
OTHER:
POLICY #
IN CASE OF EMERGENCY - NOTIFY
RELATIONSHIP
STREET ADDRESS
APT
CITY
STATE
ZIP
PHONE
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