Life File Template Details

A file of life form is a list of contact information for individuals who should be notified in the event of your untimely death. This document can be created with the help of a lawyer or through an online service. Having a file of life form in place will help to ensure that your loved ones are not left scrambling in the event of your death. In addition, it is important to keep your file up-to-date, so make sure to contact your loved ones regularly and update your information as needed. Having a file of life form in place is just one step you can take to ensure that your loved ones are taken care of after you're gone.

Below is the details relating to the file you were in search of to fill out. It can tell you the span of time you will need to finish file of life form, exactly what fields you need to fill in and several other specific facts.

QuestionAnswer
Form NameFile Of Life Form
Form Length3 pages
Fillable?Yes
Fillable fields187
Avg. time to fill out38 min 13 sec
Other namesprintable file of life forms, file of life form blank, file of life template, life file template

Form Preview Example

LIST ALL MEDICINES YOU

ARE CURRENTLY TAKING

Please list prescriptions and over-the-counter medications (ex: aspirin, antacids) and herbals (ex: ginseng, ginkgo).

Make sure you include medications that you are taking routinely

and “as needed.”

Name of prescription,

 

How Often

Reason

Over-the-counter medication,

 

 

You Take

For Taking

vitamins/supplements & dose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMERGENCY MEDICAL INFORMATION

In cooperation with: Sussex County Sheriff’s Dept.,

Sussex County Senior Services, Local Vol. Fire

and Ambulance Companies, & Delaware State Police

(Use your computer to complete this section )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Updated:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex: Male / Female

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Care Doctor:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preferred Pharmacy:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Insurance Co.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Medical Insurance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare / Medicaid:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Living Will: Yes /

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Care Power of Attorney: Yes /

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMERGENCY CONTACTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL DATA

 

Recent Surgeries/Hospitalizations:

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Update this form whenever you have a change of medication or medical history.

Keep a copy of this form in your File of Life magnetic packet, which should be placed on your refrigerator. A copy of this form also should be kept in your wallet or purse in case of emergency. For additional copies of this form or to receive a new magnetic packet, please contact Beebe Medical Center’s Community Relations Dept. at 302-645-3468. This form can also be obtained and filled out online at www.beebemed.org.

(over)

Tear on perforation and insert your updated File of Life form

into your magnetic pocket.

MEDICAL CONDITIONS

(check all that apply)

 

HEART DISEASE

LUNG DISEASE

KIDNEY

 

 

 

 

 

 

DISEASE

 

 

 

CHF/Heart Failure

 

COPD/Emphysema

 

Failure

 

 

 

 

 

 

 

 

 

 

 

High Blood Pressure

 

Asthma

 

Insufficiency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Low Blood Pressure

 

Fibrosis

 

Dialysis

 

 

 

High Cholesterol

 

Pneumonia

 

Kidney Stones

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Irregular Heart Beat

 

Bronchitis

 

Infections

 

 

 

 

 

 

 

 

Pacemaker

 

Shortness of Breath

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart Attack

 

Coughing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Angina or Chest Pain

 

Lung Pain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart Surgery/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ByPass/Stent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STOMACH

NEUROLOGICAL

MALIGNANCY/

DISEASE

DISEASE

CANCER

Bowel Obstruction

Stroke

Lung

Bleeding

Bleeding in Brain

Liver

Diverticulitis

Seizures

Breast

Hiatal Hernia

Multiple Sclerosis

Stomach

 

 

GERD/Reflux

 

 

Parkinson

 

 

Leukemia

 

 

Diarrhea

 

Headaches

 

 

Colon

 

 

 

 

 

 

 

 

 

 

 

Blood in Stools

 

Alzheimers or

 

 

Skin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Memory Loss

Other:

ENDOCRINE

OTHER

 

DISEASE

 

 

Diabetes

Arthritis

Vision

Thyroid:

Back Problem

Problems

High

HIV

Other

Low

Sickle Cell

 

Weight Gain

Weight Loss

ALLERGIES

(check all that apply)

 

 

 

Aspirin

 

 

Laytex

 

 

Tetracycline

 

 

 

 

 

 

 

 

 

 

 

 

 

Barbiturates

 

 

Lidocaine

 

 

X-Ray Dye

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Codeine

 

 

Morphine

 

 

No Known Allergy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Demerol

 

 

Novocain

 

 

Other:

 

 

 

 

 

 

 

 

 

 

Insect Stings

 

 

Penicillin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Horse Serum or

 

 

Sulfa

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vaccines

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Update this form whenever you have a change of medication or medical history.

Keep a copy of this form in your File of Life magnetic packet, which should be placed on your refrigerator. A copy of this form also should be kept in your wallet or purse in case of emergency. For additional copies of this form or

to receive a new magnetic packet, please contact Beebe Medical Center’s Community Relations Dept. at 302-645-3468. This form can also be obtained and filled out online at www.beebemed.org.

UNIVERSAL MEDICATION FORM

(Use pencil on this form to allow for easy changing)

Date Updated:

Name:

Address:

Sex: Male / Female

Date of Birth:

 

 

 

 

 

 

Primary Care Doctor:

Phone #:

Preferred Pharmacy:

Phone #:

Medical Insurance Co.:

Policy #:

Other Medical Insurance:

Policy #:

Medicare / Medicaid:

Policy #:

MEDICINE ALLERGIES/REACTIONS (describe reaction)

Drug:Reaction:

How to Edit File Of Life Form

It is simple to get forms applying our PDF editor. Updating the file for life file is simple should you keep up with the next actions:

Step 1: In order to start, select the orange button "Get Form Now".

Step 2: You can now edit your file for life. You should use the multifunctional toolbar to include, erase, and alter the content of the form.

The next parts are included in the PDF document you will be filling in.

step 1 to completing printable file of life form

Write the data in Policy #:, Medicare / Medicaid:, Policy #:, Living Will: Yes / No, Health Care Power of Attorney: Yes, EMERGENCY CONTACTS, Name:, Address:, Name:, Phone #:, and Phone #:.

printable file of life form Policy #:, Medicare / Medicaid:, Policy #:, Living Will: Yes / No, Health Care Power of Attorney: Yes, EMERGENCY CONTACTS, Name:, Address:, Name:, Phone #:, and Phone #: fields to fill

In the Address:, MEDICAL DATA, Recent Surgeries/Hospitalizations:, Date:, Update this form whenever you have, Keep a copy of this form in your, (over), Tear on perforation and insert, and into your magnetic pocket segment, focus on the significant details.

step 3 to filling out printable file of life form

The HEART DISEASE, LUNG DISEASE, KIDNEY DISEASE, CHF/Heart Failure, COPD/Emphysema, Failure, High Blood Pressure, Low Blood Pressure, Asthma, Fibrosis, Insufficiency, Dialysis, High Cholesterol, Pneumonia, Kidney Stones, Irregular Heart Beat, Bronchitis, Infections, Pacemaker, Heart Attack, Shortness of Breath, Coughing, Angina or Chest Pain, Lung Pain, Heart Surgery/ ByPass/Stent, Date Updated:, Name:, Address:, Sex: Male / Female, Date of Birth:, Primary Care Doctor:, Phone #:, Preferred Pharmacy:, STOMACH DISEASE, NEUROLOGICAL MALIGNANCY/ DISEASE, CANCER, and Phone #: section is where each party can insert their rights and responsibilities.

printable file of life form HEART DISEASE, LUNG DISEASE, KIDNEY DISEASE, CHF/Heart Failure, COPD/Emphysema, Failure, High Blood Pressure, Low Blood Pressure, Asthma, Fibrosis, Insufficiency, Dialysis, High Cholesterol, Pneumonia, Kidney Stones, Irregular Heart Beat, Bronchitis, Infections, Pacemaker, Heart Attack, Shortness of Breath, Coughing, Angina or Chest Pain, Lung Pain, Heart Surgery/ ByPass/Stent, Date Updated:, Name:, Address:, Sex: Male / Female, Date of Birth:, Primary Care Doctor:, Phone #:, Preferred Pharmacy:, STOMACH DISEASE, NEUROLOGICAL MALIGNANCY/ DISEASE, CANCER, and Phone #: fields to complete

Complete the form by checking the following sections: Drug:, Reaction:, Thyroid:, High, Low, Aspirin, Barbiturates, Codeine, Demerol, Insect Stings, Back Problem, HIV, Sickle Cell, Weight Gain, Weight Loss, ALLERGIES (check all that apply), Laytex, Lidocaine, Morphine, Novocain, Penicillin, Problems, Other, Tetracycline, X-Ray Dye, No Known Allergy, Other:, Horse Serum or, Sulfa, and Vaccines.

step 5 to finishing printable file of life form

Step 3: When you are done, press the "Done" button to transfer your PDF document.

Step 4: Generate copies of the file - it can help you keep away from possible future difficulties. And don't get worried - we do not display or view your data.

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