1. Wise Health Care Choices

Telephone Numbers & Information

Emergency Medical Service (EMS): _______________________________________________________________

Fire: ________________________________________  Police: _________________________________________

Poison Control Center:  800.222.1222

Local Poison Control Center:  ____________________________________________________________________

National Suicide Prevention Lifeline:  800.273.8255

Health Care Providers

Name / Specialty / Telephone Number: _____________________________________________________________

Name / Specialty / Telephone Number: _____________________________________________________________

Name / Specialty / Telephone Number: _____________________________________________________________

Name / Specialty / Telephone Number: _____________________________________________________________

Pharmacy & Telephone Number: __________________________________________________________________

Hospital & Telephone Number: ___________________________________________________________________

Employee Assistance Program (EAP): ______________________________________________________________

Health Insurance Information

Company & Telephone Number: __________________________________________________________________

Address: _____________________________________________________________________________________

Policyholder’s Name & Policy Number: ____________________________________________________________

What to Tell Your Doctor or Provider

(Make copies as needed.)

Use this summary when you call or visit a doctor or provider.

Symptoms

1. •Pain
   

2. •Nausea/vomiting
   

3. •Skin problems
   

4. •Eye, ear, nose, throat problems
   

5. •Fever/chills
   

6. •Breathing problems
   

7. •Stomach problems
   

8. •Muscle or joint problems
   

Other problems:  _______________________________________________________________________________

Specific questions I have now: ____________________________________________________________________

What I need to do:  _____________________________________________________________________________

Medications

Current Medications

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Medication Allergies

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________