4 – Form AOHHF1©  Are You Multi-Lingual?

ARE YOU MULTI-LINGUAL?

  DO You Have Family and Friends Who Are Not And Do Not Speak English?

Are You Willing To Protect Them With Information That Can Save Their Life in an Emergency?

Ask Here For A Medical History Form That You Can Fill Out For Them, And They Can Carry in Case They Need Medical Care When Alone.

Thank You!

6 - Form AOHHF3© 
Start Copy and Paste Below The Dotted Line
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English Medical History Form For Non-English Speakers

English Medical History for  (Name)________________________________  Who Speaks Only (Language) ____________________________

Created by __________________________On______________________Tel.________________________

 My Medical Information (Make One for Each Family Member & Keep It with You for Emergencies)

Name ______________________________________________________                              Phone#_____________________________________________________

Birthdate____________________________________________________                              Birthplace___________________________________________________

Address________________________________________________________________      City_______________________ State__________  Zip________________________________

Emergency contact – Name ________________________________________________     Phone _______________________Relation_______________________

Primary Care Physician – Name __________________________ Phone______________  Specialist Physician – Name _____________________________ Phone_____________

Specialist Physician – Name _____________________________ Phone_____________    First Hospital Choice – _________________________________________________________

My History – Surgery or Medical Condition                                                                                                                                                             Dates

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Diabetic?____Yes  ____No

My Diagnoses, Medications & Dosages __________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I am allergic to: _________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________

Blood Type __________________________________________________  Insurance Co. _______________________________________________ Phone________________

Policy Group____________________________________________         ID#________________________________

Other Important Information ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other Contacts  –

Name ____________________________________________________________Language________________ Phone ___________________________Relation____________________________________

Name ____________________________________________________________Language________________ Phone ___________________________ Relation____________________________

Based On the Writings of Rev. Mike Wanner who channels the Angel Of  Healing – Raphael  – Rev. Mike Wanner * mikewann@voicenet.com * www.AngelRaphaelSpeaks.com

Compliments Of_______________________________________________________________________________

________________________________________________________________________________

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