Age: 93
Gender: Female
PHN:
Languages: English
Ethnicity:
Height: 71 inches
Weight: 195 lbs
Blood Type: A+
Organ Donor: Yes
Home Phone:
Mobile Phone:
555-123-3456
555-555-1234
Physical Address:
Mailing Address:
Note to First Responders:
I am legally blind as I have macular degeneration, but I still wear glasses to help with my peripheral vision.
I am on WARFARIN and I have a valid DNR
Emergency Contacts
Role
|
Name
|
Relation
|
Phone
|
Primary |
Burt Hicks |
Brother |
555-555-2431 |
Alternate |
Cindy Lou |
Daughter |
504-555-7896 |
Health Practitioners
Name
|
Specialty
|
Phone
|
Dr. DoLittle |
GP |
|
Dr. Perma |
Podiatrist |
444-123-3333 |
Dr. Smith |
gynocologist |
555-456-6677 |
Dr. Tooth |
dentist |
678-555-5555 |
Dr. Vyslrien |
Cardiologist |
555-236-1212 |
Key Contacts
Name
|
Role
|
Phone
|
Burt Demo |
brother |
555-555-6767 |
Petra Demo |
daughter |
555-555-8989 |
Personal Healthcare Goals
-
Increase Exercise
-
Other Goals: Keep up walking, even if only walking hallway in my apartment
Stay engaged with people
Allergies & Sensitivities
Allergen
|
Type
|
Life Threat?
|
sulfa |
Allergy |
Yes |
codiene |
Sensitivity |
No |
Meds & Supplements (Taking)
Prescription
|
For
|
Dosage
|
bisoprolol |
cardiac |
2.5mg |
furosemide |
heart and blood pressure |
40mg |
Warfarin |
irregular heartbeat, pacemaker |
3mg |
Non-Pres
|
For
|
Dosage
|
iron pills |
low iron due to decreased kidney function |
|
Vitamin/Sup
|
For
|
Dosage
|
daily multi vitamin |
|
|
Meds & Supplements (Not-Taking)
Vaccines & Immunizations
Vaccination
|
Received
|
Next
|
Phyzer |
Nov 2 2021 |
|
Moderna |
May 25 2021 |
|
pnemonia shot |
Feb 14 2018 |
|
Cancers Past & Present
Type
|
Year
|
Stage
|
Treatment
|
breast
| 2019
| 1
| No Evidence of Disease
|
skin
| 2011
| 1
| No Evidence of Disease
|
Surgeries & Procedures/Implants
Surgery
|
Done by
|
Date
|
prolapsed uterus |
Dr. Giddian |
2013-12-31 |
gallbladder removed |
(can't remember) |
1996-12-31 |
Procedure/Implant
|
Done by
|
Date
|
mammogram |
|
2019-12-31 |
pacemaker |
Dr. Wiseman |
2016-12-31 |
Mobility & Sensory Issues
-
Walker
-
Hearing Aide(s)
-
Glasses
Family History & Additional Conditions
-
mother died at 78 from ovarian cancer
- father died of lung disease at 81
- sister died at 84 from dementia complications
- sister died at 82 from strokes
My Heart
-
Hypertension (High Blood Pressure)
-
Angina
-
Irregular heartbeats or rhythms (Arrythmia)
-
Congestive Heart Failure/Heart Failure
My Lungs
-
Chronic Bronchitis
-
COPD ()
-
Mild - take daily puffer for
My Abdominal
-
IBS
-
chronic diarrhea
-
Diabetes mellitus (Insulin dependent or non-insulin dependent)
Note: Type Type 2
-
got when I was 78 yrs old
also have hyperthyroidism for 40 yrs
My Organs
-
Chronic Kidney Desease
-
told by my GP that my kidneys are starting to fail
My Bones, Muscles & Nervous System
-
Severe Chronic Pain
Note: Type gout, 2018-01-22, tylenol daily
My Priorities
- Quality of life over Quantity
My Concerns
- Being in pain
- Being a burden
- Loss of control
- Living in a facility
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