LIFELINE RESCUE

WE SAVE LIFE

MEMBER INFORMATION SHEET

 

* Please print out and answer. Separate forms are needed for each person to be enrolled. Fax

or mail completed forms to Lifeline. Memberships will be activated upon receipt of forms and

payment/proof of payment (deposit slip). Membership cards will be issued shortly thereafter.

 

NAME:___________________________________________________________________________

                                    LAST                           FIRST                             MIDDLE

BIRTH DATE(MM/DD/YY)_______________________SEX: F___ M___

AGE: ______ CIVIL STATUS: _______ BLOOD TYPE: _______

NATIONALITY: FILIPINO ____ OTHERS ______________________________

HOME ADDRESS: _____________________________________________________________________

______________________________________________________________________________________

TEL: _________________ FAX: _________________

PLACE OF WORK: ___________________________________________________________________

TEL: ________________ FAX: __________________

ATTENDING /FAMILY PHYSICIAN: ______________________________________________

ADDRESS (HOSPITAL /CLINIC): ______________________________________________________

HISTORY OF PAST DISEASES:

WHAT WHEN

_____________________________________________________________________________________

______________________________________________________________________

PREVIOUS OPERATIONS:

WHAT WHEN_______________________________________________________________________

_______________________________________________________________________

KNOWN ALLERGENS: _____________________________________________________

DISEASES PREVALENT IN THE FAMILY:

HPN ____ DIABETIC MELLITUS ____ ALLERGY ____ ASTHMA____

TB____ HEART DISEASES _____ CANCER _____

PRESENT ILLNESS (IF ANY) AND MEDICATIONS TAKEN: _________________________

________________________________________________________________________

HABITS:

SMOKER: YES _____ NO_______

ALCOHOL DRINKER: LIGHT______ MODERATE ______ HEAVY_________

DRUG DEPENDENT: YES ______ NO _______

IF YES, PLS. SPECIFY: _______________________________________________

                                                                         

                                                                                                                                                         

 

 

 

 

 

 

ENROLLMENT FORM