Share this summary of your health with any new doctor or specialist. It can be an easy reference when you are filling out forms.
| MY PERSONAL INFORMATION | |
| Name: | Annie Jones |
| Address: | 10 Rainbow Drive, Louisville, KY 40206 |
| Date of Birth: | 12/28/97 |
| Marital Status: | Single |
| Preferred Phone Number: | 502-555-7959 |
| Alternate Phone Number: | N/A |
| E-Mail: | N/A |
| Height: | 4' 6" |
| Weight: | 65 |
| Blood Type: | O+ |
| Preferred Language: | English |
| MY EMERGENCY INFORMATION | |
| EMERGENCY CONTACTS | |
| Emergency Contact Name | Mary Jones |
| Relationship: | Mother |
| Emergency Contact Phone Number: | 502-555-7959 |
| Emergency Contact Alternate Phone Number: | 502-555-8752 |
| ADVANCE DIRECTIVES | |
| Resuscitation Status: | None |
| Organ Donor: | No |
| Source: | |
| MY INSURANCE INFORMATION | |
| Insurance Name: | 123 Insurance |
| Insurance Type: | Medical |
| Effective Date: | 1/1/06 |
| Claims Address: | 100 Main St, Louisville, KY |
| Phone Number: | 800-555-6491 |
| Insurance Name: | 321 Insurance |
| Insurance Type: | Dental |
| Effective Date: | 1/1/06 |
| Claims Address: | 100 Main St, Louisville, KY |
| Phone Number: | 800-555-6491 |
| MY DOCTORS | |
| Primary Care Provider: | Dr. Catherine Jackson, Pediatrician |
| Specialist: | Dr. Dan Miller, Pulmonologist Dr. Alice Miller, Allergist |
| Vision: | N/A |
| MY IMMUNIZATIONS | |
| Tetanus | Date of Immunization: 4/5/06 |
| Influenza | Date of Immunization: 10/27/06 |
| Pneumococcal | Date of Immunization: 12/5/06 |
| MY FAMILY HISTORY | ||
| Mother: Mary Jones | Status: Living | Diagnosis: Type 2 Diabetes |
| Father: Sam Jones | Status: Living | Diagnosis: High blood pressure, High cholesterol, seasonal allergies |
| MY MEDICATIONS | |
| PRESCRIPTIONS | |
| Albuturol | Date prescribed: 4/11/04 |
| Advair Diskus | Date prescribed: 3/28/05 |
| Zyrtec | Date prescribed: 2/6/04 |
| Flonase | Date prescribed: 4/17/06 |
| OVER THE COUNTER | |
| Multi-vitamin | Date started: 8/9/05 |
| MY ALLERGIES | |
| ENVIRONMENTAL | |
| Allergen: | Pollen, dust mites, dogs/cats, molds |
| FOOD | |
| Allergen: | Peanut butter |
| MEDICINE | |
| Allergen: | Penicillin |
| MY DIAGNOSES | |
| SELF-REPORTED CONDITIONS | |
| Wheezing | 3/2/07 |
| DIAGNOSES REPORTED BY DOCTOR | |
| Allergic Asthma | 4/11/04 |
| MY LAB TESTS AND PROCEDURES | |
| Pulmonary Function Test | Date of Test: 3/4/06 |
| Chest x-ray | Date of Test: 3/4/06 |
| MY VISITS | |
| Dr. Office | Length of Stay: |
| Children's Hospital | Length of Stay: 3/4/06-3/5/06 |
