Thought this might be helpful

[Guest guest]

Since I have gotten older, my medications have increased, my mind has gotten

worse. My husband made up a form for me He lists any information that anyone

could ever ask. You know when you go to the doctor and they want to know all

your med's and how you take them and what they are for.

I always write in SEE LIST.

I keep this on my computer and print it out for every doctor I go to.

Sometimes I just take an update copy of my med's when you are going to other

doctor's.

I have all my insurance info, every number on the card front and back.

How many times are you asked questions and you have to say I don't know.

Not any more.

When I go to the hospitals, I had them a copy and they just sit and write

down all the answers/

I take care of a gentlemen who has had 7 heart attacks and 5 open heart

surgeries and over 17 angioplasties. You think I can remember all those dates.

No

way. I hope this will be helpful to someone.

Any information on here is used only as an example.

Thanks

Norma/Ohio

Street

City, State & Zip Code

Home Phone, Cell

Social Security Number

Date of Birth

EMERGENCY CONTACT:

Name (relationship)

Street

City, State & Zip

Home Phone & Cell

MEDICATIONS:

EXAMPLE

Name 20 MG 2 x (stomach) (1/2 in AM 1/2 in PM)

AS NEEDED BASIS ONLY

INSURANCE INFO

Name

Card PPO ID Number:

Group Number:

Dental Contract# Group #

Prescription Drug Program IIN# Control #

Account# ID#

SURGERYS:

Gall Bladder 1978 Shoulder

Surgery 2002

Hysterectomy 1983 Breast

Reduction 10-31-2003

Appendix 1998 Abdominal

Plasty 01-16-2004

Gastric Bypass 09-24-2001 Bunion Ectamy

02-16-2006

Right Shoulder Replacement 02-15-2008

Complete Removal of Goiter and Thyroid 3-11-2008

OTHER:

Heart Cath 02-08-2000

TEE- Mild concentric left ventricular hypertrophy with ejection fraction of

60%

Pulmonary Function Test

Brain Scan Date, results

MRI of Brain Date results

Pneumonia Shot Date

Sleep Apnea

Fibromyalgia

TIA

Broke right arm at shoulder 12-27-2001

Broke right arm at shoulder 06-22-2005

Complete Shoulder Replacement 02-15-2008

HOSPITAL & PHARMACY

Hospital address

Phone Number

Wal-Mart (Pharmacy)

Address

Phone Number

DOCTORS:

Dr. (Family Doctor)

Address

Phone

Fax

Dr. (Pulmonary)

Address

Phone

Fax

Dr. (Foot Care)

Address

Phone

Fax

Dr. (Heart)

Address

Phone

Fax

(Dentist)

Address

Phone

Fax

Dr. (Plastic Surgeon)

Address

Phone

Fax:

Bariatric Care Center Of Ohio

Address

Phone

Fax

Dr. (Orthopedic)

Address

Phone Fax

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