Print/Save Plan

My Healthcare Plan

Naveen DEMO Hicks


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
My Documents
My Health Information:
Emergency Contacts
Role Name Relation Phone
Primary Burt Hicks Brother 555-555-2431
Alternate Cindy Lou Daughter 504-778-7896
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
Preferred Pharmacy
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
Medications & Supplements
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
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 Brain
My Mental Health
My Bones, Muscles & Nervous System
  • Severe Chronic Pain
    Note: Type gout, 2018-01-22, tylenol daily
My Auto-Immune Disorders

My Priorities
  • Quality of life over Quantity
My Concerns
  • Being in pain
  • Being a burden
  • Loss of control
  • Living in a facility
Last Updated: Jul 10 2024
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