Emergency Information Form for Children With Special Needs United States AK Bedford Kalamazoo 28900 123 Main Street Miss Pebbles Flintstone United States AK Bedford Kalamazoo 28900 123 Main Street Mrs. Wilma Flintstone US AK Bedford Kalamazoo 28900 123 Main Street Etana PPO United States AK Llama New Brunswick 282900089 Shirley Way Bedrock PPO Etana PPO Mrs. Beautrice Flintstone III Mrs. Betty Rubble III Dr. Rocky Slagstone Bedrock Family Practice
Medications
Medication Instructions Start Date Status
Albuterol inhalant 2 puffs QID PRN wheezing   Active
Clopidogrel (Plavix) 75mg PO daily   Active
Metoprolol 25mg PO BID   Active
Prednisone 20mg PO daily Mar 28, 2000 Active
Cephalexin (Keflex) 500mg PO QID x 7 days (for bronchitis) Mar 28, 2000 No longer active
Etana PPO Albuterol inhalant Clopidogrel Plavix Metoprolol Prednisone Cephalexin Keflex
Summary Purpose Transfer of care
Payers
Payer name Policy type / Coverage type Covered party ID Authorization(s)
Good Health Insurance Extended healthcare / Self 14d4a520-7aae-11db-9fe1-0800200c9a66 Colonoscopy
Good Health Insurance
Advance Directives
Directive Description Verification Supporting Document(s)
Resuscitation status Do not resuscitate Dr. Robert Dolin, Nov 07, 1999 Advance directive
Functional Status
Functional Condition Effective Dates Condition Status
Dependence on cane 1998 Active
Memory impairment 1999 Active
Problems
Condition Effective Dates Condition Status
Asthma 1950 Active
Pneumonia Jan 1997 Resolved
Pneumonia Mar 1999 Resolved
Myocardial Infarction Jan 1997 Resolved
Family history Father (deceased)
Diagnosis Age At Onset
Myocardial Infarction (cause of death) 57
Hypertension 40
Mother (alive)
Diagnosis Age At Onset
Asthma 30
Social History
Social History Element Description Effective Dates
Cigarette smoking 1 pack per day 1947 - 1972
" None 1973 -
Alcohol consumption None 1973 -
1 pack per day None None
Allergies, Adverse Reactions, Alerts
Substance Reaction Status
Penicillin Hives Active
Aspirin Wheezing Active
Codeine Nausea Active
Medical Equipment
Supply/Device Date Supplied
Automatic implantable cardioverter/defibrillator Nov 1999
Total hip replacement prosthesis 1998
Wheelchair 1999
Good Health Prostheses Company
Immunizations
Vaccine Date Status
Tetanus and diphtheria toxoids, IM 1997 Completed
Influenza virus vaccine, IM Dec 1998 Completed
Pneumococcal polysaccharide vaccine, IM Dec 1998 Completed
Tetanus and diphtheria toxoids, IM 1998 Completed
Influenza virus vaccine, IM Nov 1999 Completed
Influenza virus vaccine, IM 2000 Completed
Influenza virus vaccine, IM Oct 2001 Completed
Influenza virus vaccine, IM Sep 2002 Completed
Influenza virus vaccine
Influenza virus vaccine
Pneumococcal polysaccharide vaccine
Tetanus and diphtheria toxoids
Vital Signs
Date / Time: Nov 14, 1999 April 7, 2000
Height 177 cm 177 cm
Weight 86 kg 88 kg
Blood Pressure 132/86 mmHg 145/88 mmHg
Results
  March 23, 2000 April 06, 2000
Hematology
HGB (M 13-18 g/dl; F 12-16 g/dl) 13.2  
WBC (4.3-10.8 10+3/ul) 6.7  
PLT (135-145 meq/l) 123*  
Chemistry
NA (135-145meq/l)   140
K (3.5-5.0 meq/l)   4.0
CL (98-106 meq/l)   102
HCO3 (18-23 meq/l)   35*
M 13-18 g/dl; F 12-16 g/dl
Procedures
Procedure Date
Total hip replacement, left 1998
Encounters
Encounter Location Date
Checkup Examination Etana PPO Apr 07, 2000
Checkup Examination Etana PPO
Plan
Planned Activity Planned Date
Pulmonary function test April 21, 2000