MedCard for:
Name:______
______
Date of Birth: ______
Phone:______
Emergency Contact:
Name:______
Phone:______
Please fold and place in wallet; let skipper/crew know location of this card at pre-cruise checkout. / My Health Conditions: / Always Ask:
- What is the name of the medicine?
- What is it for?
- How and when should I take it?
- How long do I take it?
- Do I need to stay away from any foods, drinks, other medicines or activities while I take this medicine?
- Are there any side effects?
- What do I do if they happen?
- Where can I find out more about this medicine?
Arthritis / Liver problems
Diabetes / Joint replacement
Cancer / Contact lenses
Stroke / Dentures/partials
Seizures / Lens implant (in my eye)
Lung problems / Pacemaker (for my heart)
Heart problems / Defibrillator (for my heart)
High blood pressure / Hearing aid
Kidney problems / Other:______
Advance Directives I Have:
Living Will DNR / Organ Donor
Durable Power of Attorneyfor Health Care
Neither / Hospice
Past Surgeries (Operations) / Year / My Doctor and Pharmacy
Doctor Name:
Doctor Phone Number:
Pharmacy Name:
Pharmacy Phone Number:
Other Doctors (specialists):
Allergies
(Medicine, Food, Latex, etc) / Reaction
(What happens)
Vaccination Dates:
Flu:MMR:
Pneumonia:
Tetanus/diphtheria:
Instructions-Fill out this card and keep it in your wallet. When sailing, be sure that during check out you inform skipper and crew of the location of this card, so that the crew can find it if you become ill or injured.
Bring this card to all doctor’s appointments and have the medication list updated if anything changes.
You can usually obtain a wallet card like this from your doctor or pharmacist; AARP will send you one for free. Websites where you can create your own are listed below:
Personal Medicine Record for:______
- Use a pencil to list all medicines taken, including prescriptions, eye drops, inhalers/nebulizer, oxygen, creams and ointments, birth control pills, etc.
Date / Medicine / How much? (strength/dose) / How often do I take it? / What is it for? / Doctor who prescribed it?
Over the counter medicines (medicines you can buy without a doctor’s order): (check all that you use regularly)
Allergy medicine, antihistamines Cold/cough medicines LaxativesPain, headache or fever
Antacids (for heartburn or stomach) Diet pills Sleeping pills Vitamins, Minerals
Herbal, dietary supplements, hormones Aspirin Other (list):______