Coastal Empire Polio Survivors Association, Inc.

Health Data Form

 

Patient Name __________________________________________­­_____Date of Birth _____________Sex:  ____M ____F

 

 

Address         _____________________________________________________________________________________

                       _____________________________________________________________________________________

 

 

Phone Number (      ) ____________________________Cell Number (      ) ___________________________________

 

 

Next of Kin _______________________________________________________________________________________

                            Name                                                            Relationship                                         Phone Number

 

 

Other Contacts____________________________________________________________________________________

                            Name                                                            Relationship                                         Phone Number

 

 

                        ____________________________________________________________________________________

                          Name                                                              Relationship                                          Phone Number

 

 

Living Arrangements (e.g., living alone):_________________________________________________________________

 

 

Church Affiliation:  __________________________________________________________________________________

                                          Church                                               Clergyperson                                         Phone Number

 

 

Primary Insurance __________________________________________________________________________________

                                          Company                                        Phone Number                                    Policy Number

 

_________________________________________________________________________________________________

                            Insured Name                                                                             Relationship to Patient

 

Secondary Insurance _______________________________________________________________________________

                                          Company                            Phone Number                    Policy Number

 

_________________________________________________________________________________________________

                            Insured Name                                                                             Relationship to Patient

 

 

Hospital Preferred/Required: ___________________________________________________

 

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Advance Directives:  Check all that apply. 

 

              Living Will _____   Durable Power of Attorney for Healthcare _____       Attached ________________

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List all individuals who may receive information about your condition upon request:

 

Name

Relationship

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List all individuals who are restricted from receiving information regarding your condition:                        Page 2

 

Name

Relationship

 

Name

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physicians (All who are treating you):

 

Physician Name

Phone Number

 

Physician Name

Phone Number

Primary Physician

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Diagnoses:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Past Medical and Surgical History (Include polio – age, type, treatment, etc.):

 

Diagnoses and Surgeries

 

Diagnoses and Surgeries

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medications (Include over the counter medications, vitamins and supplements)                                              Page 3

 

 

Preferred Pharmacy _________________________________________Phone Number ____________________________

 

 

Drug            (e.g., Tylenol)                   

Strength (e.g.,500 mg)

Dosage         (e.g., 2 tablets)

Instructions (e.g., every 4 hrs)

For What

(e.g., Pain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List Year of Last Immunizations   Flu_________ Pneumonia__________Tetanus_________

 

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 Allergies and Side Effects (Incl. Foods, Chemicals, and Other Materials)

 

Agent ( e.g. Penicillin)

Reaction (e.g. Rash)

 

Agent (e.g. Tape)

Reaction (e.g. Blister)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Other Treatments (e.g., Oxygen, Sitz Bath, etc.)

 

Treatment

Instructions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List all implanted medical devices (e.g. Pacemaker, Stents, Shunts)                                                        Page 4

 

 

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

 

 

 

Special Accommodations (e.g., elevate head of bed when sleeping or pillow under knees)

 

 

__________________________________________________________________________________________________

 

__________________________________________________________________________________________________

 

__________________________________________________________________________________________________

 

 

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Special needs (e.g. Low vision or non-ambulatory – uses wheelchair or scooter)

 

__________________________________________________________________________________________________

 

__________________________________________________________________________________________________

 

__________________________________________________________________________________________________

 

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Adaptive Equipment (e.g. Cane, Brace, Crutches)

 

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

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Organ/Body Donor:    No __ Yes __  If Yes, please list contact information

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

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Patient Signature ______________________________________________________Date_________________________

 

Witness Signature______________________________________________________Date_________________________