Wallet Medical History/Medication Card

[Guest guest]

Hi!

Here is a draft of a PSC specific medical history/medication card.

What I have on computer is sized, when folded in half, as a business

card (fits in wallet). Outside is history, inside is

medication/allergy list. My original has two copies on one 8 1/2 by

11 paper, so that card can easily be re-copied to reflect

changes/updates. I will work on making it " prettier " , but wanted

feedback if I forgot something important. The card doesn't have

absolutely every detail, because the purpose is to have a portable

list which capture key items and full list of medications and allergies.

Solway's idea to carry an article or fact sheet about PSC

when traveling was great (or the PSC Partners brochure), plus copy of

recent labs (or excel spreadsheet of labs).

Please let me know if you have comments or suggestions!

Thanks.

Joanne

(, Ca)

Medical History/Medication Record

Name: ______________________________ DOB: _________

Primary MD/Tele #: ________________________________

GI MD, Hepatol/Tele #: ____________________________

___________________________________________________

Medical History/ Date of Diagnosis: _______________

___________________________________________________

___________________________________________________

___________________________________________________

Surgical History/Date: ___________________________

___________________________________________________

Procedures/Date: _________________________________

Colonoscopy: ______________________________________

ERCP: ____________________________________________

Upper Endoscopy:___________ Abd Ultrasound: ______

Liver Biopsy: ___________ Dexa (Bone Density)_____

___________________________________________________

Immunizations/Date: Tetanus:____ Pnuemovax: _____

Hepatitis A Series:___ Hep B Series:___ Influenza:_____

Advance Health Care Directive: Yes No

Organ Donor: Yes No

Allergies: ________________________________________

___________________________________________________

Medications: Name, Exact Dosage, Frequency (# Times/day)

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

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[Guest guest]

I'd recommend a spot for blood type. My " dog tag " has name, city, blood type,

UC, PSC, asthma and " only one kidney " .

Arne

Hi!

Here is a draft of a PSC specific medical history/medication card...