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: | George Stevens |
| Address: | 100 Orange Grove Rd, Fort Myers, FL 33902 |
| Date of Birth: | 7/2/47 |
| Marital Status: | Widower |
| Preferred Phone Number: | 239-555-4389 |
| Alternate Phone Number: | N/A |
| E-Mail: | George.Stevens@isp.com |
| Height: | 5' 9" |
| Weight: | 145 |
| Blood Type: | B+ |
| Preferred Language: | English |
| MY EMERGENCY INFORMATION | |
| EMERGENCY CONTACTS | |
| Emergency Contact Name | Joanna Lacy |
| Relationship: | Daughter |
| Emergency Contact Phone Number: | 914-555-8027 |
| Emergency Contact Alternate Phone Number: | 914-555-6469 |
| ADVANCE DIRECTIVES | |
| Resuscitation Status: | |
| Organ Donor: | No |
| Source: | |
| MY INSURANCE INFORMATION | |
| Insurance Name: | ABC Insurance |
| Insurance Type: | Medical |
| Effective Date: | 1/1/05 |
| Claims Address: | 123 Main Street, City, State, Zip |
| Phone Number: | 123-456-7890 |
| Insurance Name: | XYZ Insurance |
| Insurance Type: | Dental Insurance |
| Effective Date: | 1/1/05 |
| Claims Address: | 231 South Street, City, State, Zip |
| Phone Number: | 231-456-7890 |
| MY DOCTORS | |
| Primary Care Provider: | Dr. Frederick Christopher |
| Specialist: | Dr. Jessica Jones, Neurologist Dr. Dennis James, Dermatologist |
| Vision: | Dr. Alice Smith |
| MY IMMUNIZATIONS | |
| Influenza | Date of Immunization: 10/21/06 |
| MY FAMILY HISTORY | ||
| Mother | Status: Deceased | Diagnosis: Lung Cancer |
| Father | Status: Deceased | Diagnosis: Heart attack |
| Brother | Status: Living | Diagnosis: Heart Disease |
| MY MEDICATIONS | |
| PRESCRIPTIONS | |
| Mirapex | Date prescribed: 6/22/03 |
| Sinemet | Date prescribed: 10/27/06 |
| Prozac | Date prescribed: 8/5/05 |
| OVER THE COUNTER | |
| Maloxx Max | Date started: 9/21/05 |
| Philips Liqui-Gels | Date started: 5/11/05 |
| MY ALLERGIES | |
| ENVIRONMENTAL | |
| Allergen: | Pollen |
| FOOD | |
| Allergen: | None |
| MEDICINE | |
| Allergen: | None |
| MY DIAGNOSES | |
| SELF-REPORTED CONDITIONS | |
| Constipation | 5/8/05 |
| Stomach Pain | 9/21/05 |
| DIAGNOSES REPORTED BY DOCTOR | |
| Parkinson's Disease | 6/22/03 |
| MY LAB TESTS AND PROCEDURES | |
| Colonoscopy | Date of Test: 10/2/04 |
| MY VISITS | ||
| Dr. Jessica Jones | Length of Stay: 1/8/07 | |
| Dr. Frederick Christopher | Length of Stay: 10/21/06 | |
