Resident Vial of Life Form

Resident Vial of Life Form

What information do you want Oak Hammock to have if you cannot provide it in case of an emergency?

LAST NAME

FIRST NAME

REVIEW/ UPDATE DATE

Date this Form Reviewed or Updated

DATE OF BIRTH

PHONE NUMBER

HOUSE/ APT / ROOM Number

HOSPITAL PREFERENCE

Select or enter value

HOSPITAL MRN (if known)

MEDICAL RECORD NUMBER

PRIMARY CARE PHYSICIAN NAME/NUMBER

MORTUARY NAME/ CONTACT NUMBER

NEXT OF KIN

Name/Phone/Relationship to Resident

PRIMARY EMERGENCY CONTACT

ALTERNATE EMERGENCY CONTACT

Advance Directives

Select or enter value

DNR (Do Not Resuscitate)*

Select

Are you currently a primary caregiver?

Caregiver, if yes, state for whom and describe instructions

Do you currently have pet(s) in your home?

Pet, if yes, state type of pet and describe instructions

If you go to hospital, is there a friend/neighbor at OH you would like to be informed? If yes, name/phone/email:

MOBILITY

To meet your individual situation, please provide additional specific information in the space provided below in comments.

Ambulatory (Walk unassisted))

Cane

Walker/Rollator

Wheel Chair

Motorized Chair

Non-Ambulatory

Other (write in comments box)

Appliances/Aids/ Equipment/ Communication

To meet your individual situation, please provide additional specific information in the space provided below in comments.

Oxygen

Nebulizer/Breathing Treatment

CPAP

Pacemaker

Glasses

Legally Blind

Blurred Vision

Vertigo

Hard of Hearing

Hearing Aides

Dentures

Other (write in comments box)

Medical History

To meet your individual situation, please provide additional specific information in the space provided below in comments.

Anemia

Asthma

Cancer

Cognitive Impairment

COPD

Diabetes

Epilepsy

Eye Disease

Heart Disease

High Blood Pressure

Neuropathy

Stroke

Parkinson's Disease

Other (write in comments box)

Supplemental Oxygen

Select

Do you have Allergies to Medications?

If yes, please list

COMMENTS

Send me a copy of my responses

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