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File Of Life Form PDF 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.

Question	Answer
Form Name	File Of Life Form
Form Length	3 pages
Fillable?	Yes
Fillable fields	187
Avg. time to fill out	38 min 13 sec
Other names	file of life order form, file of life form, file of life printable form, file of life pdf

12

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,			How Often	Reason
Over-the-counter medication,			You Take	For Taking
vitamins/supplements & dose			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
			High Blood Pressure		Asthma		Insufficiency

			Low Blood Pressure		Fibrosis		Dialysis
			High Cholesterol		Pneumonia		Kidney Stones
			High Cholesterol		Pneumonia		Kidney Stones

			Irregular Heart Beat		Bronchitis		Infections
			Irregular Heart Beat		Bronchitis		Infections
			Pacemaker		Shortness of Breath

			Heart Attack		Coughing



			Angina or Chest Pain		Lung Pain



			Heart Surgery/


			ByPass/Stent
			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
		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
			Barbiturates			Lidocaine			X-Ray Dye

			Codeine			Morphine			No Known Allergy



			Demerol			Novocain			Other:
			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 Online for Free

Our best web programmers have worked together to make the PDF editor that you're going to use. This software makes it easy to fill in file of life card files instantly and conveniently. This is certainly everything you should do.

Step 1: Choose the button "Get Form Here" and hit it.

Step 2: After you've entered the editing page file of life card, you will be able to discover every one of the options available for the form within the upper menu.

Fill in all of the following sections to fill in the form:

file of life pdf fields to fill out

The application will require you to complete the Medicare, Medicaid Policy, Living, Will, Yes, No HealthCare, Power, of, Attorney, Yes, No EMERGENCY, CONTACTS Name, Address, Name, Address, Phone, Phone, MEDICAL, DATA Recent, Surgeries, Hospitalizations and Date segment.

file of life pdf MedicareMedicaid, Policy, LivingWillYesNo, HealthCarePowerofAttorneyYesNo, EMERGENCYCONTACTS, Name, Address, Name, Address, Phone, Phone, MEDICALDATA, RecentSurgeriesHospitalizations, and Date fields to fill out

You have to include specific details within the box HEART, DISEASE LUNG, DISEASE KIDNEY, DISEASE CH, F, Heart, Failure COPD, Emphysema Failure, High, Blood, Pressure Low, Blood, Pressure Asthma, Fibrosis, Insufficiency, Dialysis, High, Cholesterol Pneumonia, and Kidney, Stones

file of life pdf HEARTDISEASE, LUNGDISEASE, KIDNEYDISEASE, CHFHeartFailure, COPDEmphysema, Failure, HighBloodPressure, LowBloodPressure, Asthma, Fibrosis, Insufficiency, Dialysis, HighCholesterol, Pneumonia, and KidneyStones blanks to complete

The Policy, Medicare, Medicaid Policy, Drug, Reaction, Diarrhea, Blood, in, Stools ENDOCRINE, DISEASE, Diabetes Thyroid, High, Low, Aspirin, Barbiturates, Codeine, and De, mero, l area will be applied to provide the rights or responsibilities of both sides.

file of life pdf Policy, MedicareMedicaid, Policy, Drug, Reaction, Diarrhea, BloodinStools, ENDOCRINEDISEASEDiabetes, Thyroid, High, Low, Aspirin, Barbiturates, Codeine, and Demerol blanks to insert

Fill in the template by analyzing the following fields: Vaccines.

file of life pdf Vaccines fields to insert

Step 3: Select the "Done" button. Now it's easy to upload your PDF form to your electronic device. Aside from that, you may forward it through email.

Step 4: Ensure that you avoid potential difficulties by preparing a minimum of 2 duplicates of the form.

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