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Thread: Medical History Form

  1. Print this Post   #1
    Moderator danemayer's Avatar
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    Medical History Form

    As we've aged and medical procedures, surgeries, prescriptions, etc. have begun to become more numerous, and harder to remember, we've been keeping printed Medical Histories. These have proven extremely useful when going to an Emergency Room as it provides most of what the Doctors and Nurses need to capture our history. The nurse always makes a copy to attach to our chart.

    At the South Texas Chapter Rally last week, the subject of Emergency Info came up and I thought it might be helpful to share the form we've been using.

    I've made up a PDF fill-in-the-blanks Form which is attached. Save the document to your computer, open it and follow the instructions on page 1.

    I'd suggest keeping a copy in your Tow Vehicle and if possible, on your person. One for you. A separate form for your spouse.

    I hope this is helpful.
    Attached Files Attached Files
    Last edited by danemayer; 04-26-2012 at 09:43 PM. Reason: Replaced pdf file with version that can be saved from Acrobat Reader


    Dan and Ann Mayer & fur babies Callie the Rally Dog and Cooper
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  2. Print this Post   #2
    Senior Member rick_debbie_gallant's Avatar
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    Re: Medical History Form

    Well done on the list! What do you think about including a few more things:

    Blood type
    next of kin information
    contact info of persons traveling with them
    health insurance information

    just a few more ideas. again great job. Thanks for putting this together.
    Rick and Debbie Galant and Ted E. Bear
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  3. Print this Post   #3
    Moderator danemayer's Avatar
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    Re: Medical History Form

    Quote Originally Posted by rick_debbie_gallant View Post
    Well done on the list! What do you think about including a few more things:

    Blood type
    next of kin information
    contact info of persons traveling with them
    health insurance information

    just a few more ideas. again great job. Thanks for putting this together.
    I'm working on a glovebox kit; an extension of the Alabama Yellow Dot program.

    This is the 1st form with several more to follow. There'll be a separate form for emergency contacts. Another for Dependents/Pets info, which will include itinerary info so your rig can be located. Another to list insurance policy numbers and phone contacts.

    Other info that might go into the kit would include copies of your medical insurance cards, auto/RV insurance cards or declarations, Advance Medical Directives, Powers of Attorney. These would be documents you'd have to make copies of to put in the kit folder.

    As to Blood Type, you could write it on the form by hand. If there are any EMTs on the forum, maybe they could weigh in on whether medical personnel would prefer to run their own test to determine blood type, or take it off a piece of paper you're carrying.

    I have static cling window decals on the side truck windows to alert emergency personnel to the folder in the glovebox. If you like, you can order yourself a set of 2 for about $8 by using this link.

    Walmart has 6x9" clasp envelopes (6 for about $1). If you order the decals, download a copy of the artwork attached below, print it, and glue or tape it to the envelope that goes in the glovebox. Then just keep the docs current.
    YellowStickerFolder.jpg
    Last edited by danemayer; 04-25-2012 at 05:25 PM. Reason: updated link


    Dan and Ann Mayer & fur babies Callie the Rally Dog and Cooper
    2011 Landmark Rushmore
    • MorRyde 8K Independent Suspension
    • 8K Kodiak Disc Brakes
    • Goodyear G114 17.5" tires
    • RV Comfort Systems Cheap Heat
    • MorRyde 33x90 Sliding Cargo Tray
    • Torklift Glowstep Revolution Aluminum Steps & Dirt Destroyer

    2014 RAM 3500 Laramie
    • Cummins 6.7 Diesel, AISIN Transmission
    • 4x4, Long box, Crew Cab, DRW 3.73
    • Sailun Terramax A/T 4S, 235/80R -17. 5 Tires
    • Hensley BD3 TrailerSaver Hitch
    • Garmin RV760 GPS


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  4. Print this Post   #4
    Moderator danemayer's Avatar
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    Re: Medical History Form

    I've put together the additional forms:
    - Children and Pets
    - Emergency Contacts
    - Insurance
    - Travel Itinerary
    - Medical History
    The templates and image files for the folder and the decal are all downloadable at this link:



    Again, if you want to order 2 decals for about $8, you can use this link

    These forms can be printed on your printer and filled out by hand, or you can fill in the blanks and print out the completed forms. It'll be easier to maintain and easier to read if you fill in the blanks.

    You can get 6 6"x9" Clasp Envelopes from Walmart for about $1.
    Last edited by danemayer; 05-24-2012 at 02:38 PM. Reason: changed web link


    Dan and Ann Mayer & fur babies Callie the Rally Dog and Cooper
    2011 Landmark Rushmore
    • MorRyde 8K Independent Suspension
    • 8K Kodiak Disc Brakes
    • Goodyear G114 17.5" tires
    • RV Comfort Systems Cheap Heat
    • MorRyde 33x90 Sliding Cargo Tray
    • Torklift Glowstep Revolution Aluminum Steps & Dirt Destroyer

    2014 RAM 3500 Laramie
    • Cummins 6.7 Diesel, AISIN Transmission
    • 4x4, Long box, Crew Cab, DRW 3.73
    • Sailun Terramax A/T 4S, 235/80R -17. 5 Tires
    • Hensley BD3 TrailerSaver Hitch
    • Garmin RV760 GPS


    Is club membership right for you? Click here to learn more

    Check out our Owner-written User Guides and Troubleshooting Guides

  5. Print this Post   #5
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    Re: Medical History Form

    I made a chart pretty similar after a miserable try at explaining to a traveling Er Pulmonary Dr the sequnce of events in my life starting at Stage 4 colon cancer to the Diabeties dx to the Wegeners Vasculitus dx and all that the damage it caused and then they ordered Lasix and kept me 6 days and released me ofnly to return because they over loaded the lasix and my potassium level both dropped. I was home one day and had to be readmitted worse than I was the week before, with pneumonia. This after I told the nurse I take the Lasix only as needed for the water retention from my kidney disease and to my knowledge had nothing to do with my COPD. Good idea to have a chart like you did but I filled a whole page with my info on each subject,Meds I take reach 26 pills a day. It also included family history of Diabetes and cancer etc. I wouldnt be with out a chart like you gave, thanks

  6. Print this Post   #6
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    Re: Medical History Form

    It is an excellent idea. My DW started doing this some years ago as it seems every other time you go to your regular doctor they want a new form filled out.

  7. Print this Post   #7
    Original Owners Club Member jmgratz's Avatar
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    Re: Medical History Form

    I bought a flashdrive with a program that keeps all of your medical information on it. You can take it with you and then give it to your doctor and/or hospital and they can put it in their computer and see all of your medical information. They sell them at RV shows. Got to admit that I have not been good at keeping it current though.
    Jim & Sheila Gratz - owners club #1018 Workamping as Sales Associate with SE Publications Certified RV Walk-through Technician [/I] 2013 Landmark San Antonio - full body paint - Fulltimer pkg, Yetti pkg etc., Mor-Ryde IS with never lube bearings and disc brakes. --previous 5er - 2007 "Classic" Landmark "Golden Gate" Replaced 9/20/13 2012 Ford F350 King Ranch Crew Cab fx4 dually, 6.7 L Husky Trailer Saver TS2 hitch "visit TEXAS - it's like a whole 'nuther country" Rally Site 414

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    Camp Socializer gasman's Avatar
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    Re: Medical History Form

    Hey Dan, we really like this idea and in fact got the kits from you in Gillette. What if you either added a space for the current date or set it up to date stamp it when the form is printed. The medical professionals would know how current the info without having to guess how old the paper is. Some of us may not be as diligent as we should be in keeping the info current.


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  9. Print this Post   #9
    Moderator danemayer's Avatar
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    Medical History Form

    Quote Originally Posted by gasman View Post
    Hey Dan, we really like this idea and in fact got the kits from you in Gillette. What if you either added a space for the current date or set it up to date stamp it when the form is printed. The medical professionals would know how current the info without having to guess how old the paper is. Some of us may not be as diligent as we should be in keeping the info current.
    The form has a field at the top right titled "Date last updated". After typing your name, the tab key will take you to that field next.

    I notice that opening the file from Tapatalk on my iPad, the field title doesn't show for some reason.


    Sent from my iPad using Tapatalk HD


    Dan and Ann Mayer & fur babies Callie the Rally Dog and Cooper
    2011 Landmark Rushmore
    • MorRyde 8K Independent Suspension
    • 8K Kodiak Disc Brakes
    • Goodyear G114 17.5" tires
    • RV Comfort Systems Cheap Heat
    • MorRyde 33x90 Sliding Cargo Tray
    • Torklift Glowstep Revolution Aluminum Steps & Dirt Destroyer

    2014 RAM 3500 Laramie
    • Cummins 6.7 Diesel, AISIN Transmission
    • 4x4, Long box, Crew Cab, DRW 3.73
    • Sailun Terramax A/T 4S, 235/80R -17. 5 Tires
    • Hensley BD3 TrailerSaver Hitch
    • Garmin RV760 GPS


    Is club membership right for you? Click here to learn more

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  10. Print this Post   #10
    Senior Member JanAndBill's Avatar
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    Re: Medical History Form

    Dan the "Yellow Dot" program is not limited to just Alabama, at present I believe there are about 22 states which offer the free packets. Here in our state the County Sheriff's Office has the packets available, I am assuming that other states would be similiar. As a Volunteer Fire & First Responder I've seen many cases where the occupants of a vehicle that were involved in a crash were not able to give us much needed basic medical information. Any time we pull up on the scene of an accident our number one priority is to get the victims care as quickly possible, the "Yellow Dot" program is just one more tool that helps us help the patient.
    Jan & Bill,Attalla, AL HOC #2576
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