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