Dr. Steiner's Tools for Change

Medical Information Form

  1. Introduction to the Medical Information Form™
  2. What the Medical Information Form™ Looks Like
  3. How to Download
  4. How to Fill Out
  5. ❧ How to Use

How to Use the Medical Information Form™

1. Take a copy of the updated form with you whenever you leave your home and know where your latest version is at all times.

2. Keep a copy in your wallet or backpack.

3. If you live alone have a copy near the most noticeable phone in your home.

4. Have your doctor's staff make a copy of it for your chart.

5. Make sure your pharmacist and dentist also have a current copy.

Space has been left for those who have special needs or who want to list the person named in their Durable Power for Health Care Decisions, a legal document that spells out your wishes about medical treatment if you are unable to speak for yourself.

Dt Steiner's Medical Form

(completed form will be the size of a credit card)

HOW TO PRINT OUT THE MEDICAL INFORMATION FORM™

This form is designed to fit onto one page that is folded to the size of a credit card. This document is intended to be printed on both sides (double-sided). It can be used as two pages or printed as a two-sided document. Refer to your printer's manual for directions to print double-sided.

If you don't want to copy the form onto your computer, but want a copy of the blank form click here for a PDF that you can print.



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© Ann Steiner, Ph.D. All rights reserved. Reproduction without the author's written consent is prohibited.

Last Updated: April 6, 2016