Medical Information Card

	Medical Information Card
	During pregnancy, its a good idea to carry your basic medical information. Use this form to generate a medical summary card that you can print and keep with you in case you need medical aid. You will have your medical info and contact numbers ready when you need them. Hospital Emergency Room personnel often experience situations where the patient can not give vital health information. A medical identification and information card would prove to be invaluable to attending medical personnel in providing treatment. Instructions: Type your information directly onto the form below. ( No information entered here will be stored for any purpose. ) Click the Create Medical Summary button. Print out your information clearly. Print as many copies as you like. Fold the printed sheet and keep in your wallet or purse. * You can revisit this form when and if your medical information changes. * When you have completed the information and printed the card, you can click on the Clear Form button and your information will be cleared. Only you will have a record.

Medical Information Card -: Fill out this form :-
About You:
First Name:
Last Name:
Address 1:
Address 2:
Telephone
Alternate Phone #:
Due Date:	/ /
Birthday:	/ /
Blood Type:
Medications:
Allergies:

About Your Insurance:
Provider:
Provider Phone:
Plan:
Policy #:
Emergency Contact Information:
Name:
Relationship to you:
Telephone #:
Alternate Telephone #:
Your Risks: Select all that apply: *( To make multiple selections, hold down the Ctrl Key as you click )*
Common risks:
Other Risks:

Medical History: Enter dates for the following:
C-Sections:
Medical Miscarriages:
Preterm Deliveries:
Toxemia/Preeclampsia:
Other Medical:	-

Please Note: Baby2see makes no guarantee or warranty with respect to the completeness or accuracy of this information. Any risk arising out of use of this information remains with the user.