Medical 
                  Summary Card

                  During pregnancy, its often a good idea to carry your basic 
                  medical information. Use this form to generate a medical summary 
                  card that you can print and keep with you in case that you need 
                  medical aid. 

              		
            

            
 
               
            

            
 
              About 
                You: 
            

            
 
               
                
First 
                  Name:

              		
                
                
                
            

            
 
               
                
Last 
                  Name:

              		
                
                
                
            

            
 
               
                
Address 
                  1:

              		
                
                
                
            

            
 
               
                
Address 
                  2:

              		
                
                
                
            

            
 
               
                
Telephone

              		
                
                
                
            

            
 
               
                
Alternate 
                  Phone #:

              		
                
                
                
            

            
 
               
                
Due 
                  Date:

              		
                
                
                / 
                
                / 
                
                
            

            
 
               
                
Birthday:

              		
                
                
                / 
                
                / 
                
                
            

            
 
               
                
Blood 
                  Type:

              		
                
                
                
            

            
 
               
                
Medications:

              		
                
                
                
            

            
 
               
                
Allergies:

              		
                
                
                
            

            
 
               
                

              		
               
            

            
 
               
                
Hola

              		
            

            
 
               
                
About 
                  Your Insurance: 

              		
            

            
 
               
                
Provider:

              		
                
                
                
            

            
 
               
                
Provider 
                  Phone:

              		
                
                
                
            

            
 
               
                
Plan:

              		
                
                
                
            

            
 
               
                
Policy 
                  #:

              		
                
                
                
            
 
               
                
Hola

              		
            

            
 
               
                
Emergency 
                  Contact Information: 

              		
            

            
 
               
                
Name:

              		
                
                
                
            

            
 
               
                
Relationship 
                  to you:

              		
                
                
                
            

            
 
               
                
Telephone 
                  #:

              		
                
                
                
            

            
 
               
                
Alternate 
                  Telephone #:

              		
                
                
                
            

            
 
               
                
Hola

              		
            

            
 
               
                
Your 
                  Risks: 

                  Select all that apply:

              		
            

            
 
               
                
Common 
                  risks:

                  

              		
               
                

                  
                

                
              		
            

            
 
               
                
Other 
                  Risks:

              		
               
                
 
                  
                  

              		
            

            
 
               
                

              		
            

            
 
               
                
Medical 
                  History: 

                  Enter dates for the following: 

              		
            

            
 
               
                
C-Sections:

              		
                
                
                
            

            
 
               
                
Medical 
                  Miscarriages:

              		
                
                
                
            

            
 
               
                
Preterm 
                  Deliveries:

              		
                
                
                
            

            
 
               
                
Toxemia/Preeclampsia:

              		
                
                
                
            

            
 
               
                
Other 
                  Medical: