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General Information
Name: John P. Doe
Gender: Male
Blood Type: O+
Date of Birth: 07/01/1878
Age: 54
Tobacco History: Yes
Quit For: 5 Years
Alcohol History: Yes
How much per Day: 6 Beers
Emergency Contacts
Name: Janet L Kirtland
Phone: 555-123-1234
Relation: Mother
Name: Joe T Kirtland
Phone: 555-123-1234
Relation: Father
Physician / Medical Contacts
Name: Dr Bob R Dole
Phone: 555-123-1234
Specialty: Herbalist
Organization: Todays Wellness
Reason for Physician: To feel better everyday from normal diet and a good exercise routine. Doctor helps me to maintain a healthy life style.
Medications / Supplements
Drug / Supplement: Glucosimine
Dose: 1000mg
Taken: Orally
How Often: Daily
Drug / Supplement: Aleve
Dose: 500mg
Taken: Orally
How Often: Daily
Allergies
Type: Drug
Name: Oxycotin
Reaction: Hives
Type: Food
Name: Avocado
Reaction: Eating causes throat to close
Diagnosed Conditions / Known Ailments
Name: Herniated Disk
Starting Date: 10/14/2001
Description: Car accident caused Herniated Disk in neck, located C3-C4.
Surgeries
Name: Disk Replacement
When: 05/08/2010
Physician: Dr Rumbult
Physician Phone: 152-123-1234
Reason: This was done to replace the Herniated Disk in the neck.
Comments: Rehab was 9 months long.
Internal Devices
Name: Heart Valve
When: 05/08/2010
Physician: Dr Rumbult
Physician Phone: 152-123-1234
Reason: This was done to replace the valve after an infection occured.
Comments: Rehab was 9 months long.
Medical Equipment Used
Name: Cane
Type: Movement Assistance
How often used: Daily
Started Using: 08/05/2014
Immunizations
Name: Smallpox
When: 10/14/1985
Booster: No
Comment:
Reactions: None
Insurance Policy
Provider: Aetna
Company: Aetna
Member ID: 1234561
Group ID: 123546
Comments: None
Hospital History
Name: St Mary's
Location: California
Visit Date: 10/14/1985
Reason: Heart Attack
Length of Stay: 5 Days
Family History
Parent: Mother
Status: Died 05/05/1974
Cause of Death: Natural Causes
Conditions: High Blood Pressure
Diagnosis:
Member Notes
Name:
Description:
Medical Files
Name: X-Ray
Location Taken: St Mary's
When: 05/05/2012
Doctor: Dr. Mary
Reason: Car Accident
File: Waiting on USPS (Expected: 9/15/2014)
Legal Documents
Name: Medical Power of Attorney
Last Updated: 05/05/2012
Location: Law Office of Rode
Phone: 123-123-1234
Name: Power of Attorney
Last Updated: 05/05/2012
Location: Law Office of Rode
Phone: 123-123-1234
Food Diet
Type: Vegan
Since: 05/05/2012
Why: Health
Comments: Have felt great since starting.
Living Situation
Name of Location: Treehouse Family
Type of Location: Assisted Living
Floor: 1
Stairs: None
With Who: Alone
Why: No children
Since: 08/01/2014
Medical Alert Button: No
Additional Files
Name: CT-SCAN Report
File: None
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