My Healthcare Plan
Last Updated: Feb 27 2023
Age: 92
Gender: Female
PHN:
Languages: English
Ethnicity:
Gender: Female
PHN:
Languages: English
Ethnicity:
Height: 71 inches
Weight: 195 lbs
Blood Type: A+
Organ Donor: Yes
Weight: 195 lbs
Blood Type: A+
Organ Donor: Yes
Home Phone:
Mobile Phone:
Mobile Phone:
555-123-3456
555-555-1234
555-555-1234
Physical Address:
Mailing 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 Contacts, Doctors, and Health Information:
Emergency Contacts
| Role | Name | Relation | Phone |
|---|---|---|---|
| Primary | Burt Hicks | Brother | 555-555-2431 |
| Alternate | Cindy Lou | Daughter | 504-778-7896 |
Doctors
| Name | Specialty | Phone |
|---|---|---|
| Dr. DoLittle | Primary Care Physician | |
| 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 |
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
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 & Implants/Procedures
| Surgery | Surgeon | Year |
|---|---|---|
| prolapsed uterus | Dr. Giddian | 2013 |
| gallbladder removed | (can't remember) | 1996 |
| Implant/Procedure | Surgeon | Year |
|---|---|---|
| mammogram | 2019 | |
| pacemaker | Dr. Wiseman | 2016 |
My Heart
-
Hypertension (High Blood Pressure)
-
Angina
-
Irregular heartbeats or rhythms (Arrythmia)
-
Congestive Heart Failure/Heart Failure
My Lungs
-
COPD (Chronic obstructive pulmonary/lung disease)
-
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 Values & Beliefs
- Quality of life over Quantity
My Fears & Concerns
- Loss of control
- Being in uncontrollable pain
- Being a burden on loved ones
- Being in a care facility
Primary Care Physician: Dr. DoLittle
Happy Clinic
123 Happy St., Newark, Inuvik
Happy Clinic
123 Happy St., Newark, Inuvik
Date Reviewed with Dr.:
Next Review with Dr.:
Next Review with Dr.:
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