DAWN Ontario
Medical Information Record

Name:______________________________________________________

Home:
Address:____________________________________________________

City:__________________________ Prov./State:___________________

Postal/Zip Code: ______________ Country: ______________________

Phone: (area code) (______)       ________________________

Medications Currently being taken: Date:_________________________

Prescription Drug Information   *Doctor or Dentist Prescribed by:

1_____________________________     *Dr.__________________________

2_____________________________      *Dr.__________________________

3_____________________________      *Dr.__________________________

4_____________________________      *Dr.__________________________

5_____________________________      *Dr.__________________________

6_____________________________      *Dr.__________________________

7_____________________________      *Dr.__________________________

8_____________________________      *Dr.__________________________

9_____________________________      *Dr.__________________________

10____________________________      *Dr.__________________________

Over The Counter Medications:
Includes All Vitamins, Minerals & Supplements & amount taken daily:

1_________________________________________________

2_________________________________________________

3_________________________________________________

4_________________________________________________

5_________________________________________________

6_________________________________________________

7_________________________________________________

8_________________________________________________

9_________________________________________________

10_________________________________________________

11_________________________________________________

12_________________________________________________

ALL Physicians, Dentist ETC. & their    *Office Phone Numbers.

1. Dr.______________________   *__________________________

2. Dr.______________________   *__________________________

3. Dr.______________________   *__________________________

4. Dr.______________________   *__________________________

5. Dr.______________________   *__________________________

6. Dr.______________________   *__________________________

List EMERGENCY CONTACT persons and their *Phone number.

1.______________________   *__________________________

2.______________________   *__________________________

3.______________________   *__________________________

List ALL allergies. Include allergies to medications, prescription or
'over-the-counter', AND all food, insect & environmental allergies.

1._________________________________________________

2._________________________________________________

3._________________________________________________

4._________________________________________________

5._________________________________________________

Blood Type: _________________

Other:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

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