|
Member Date
of last file update: 12/2/2003
|
| Name: |
John R. Johnson Sr. | Date of Birth: |
4/5/1955 |
| Address:
|
2525 Smithdale
Houston, TX77041 | Sex: |
Male |
| Phone:
|
Hm (713) 555-1212
Wk (713) 555-1213
Other | Religion: |
Catholic |
| E-mail: |
johnjohnson@smithnet.com | Bloodtype |
O- |
| Occupation: |
Marketing Representative | | |
Medical
Information
|
| Medical Conditions: |
Diabetes, Heart patient-pacemaker/AICD. Wears contact lenses.
|
|
| Drug
Allergies: |
Penicillin, Cephalosporins, Codeine. Cillium, other stuff
|
|
| Other Allergies: |
Bee stings, Latex, X-ray dye, Peanuts.
|
| Prescription
Medications Taken: |
Epi-pen for allergies. Taking Coumadin, Procardia and Aspirin. On Insulin pump.
|
|
| Over-the-counter Medications: |
Multi-vitamin, Folic Acid.
|
|
Important
Documents (click item listed below to view scanned
document)
|
| This member has included the following important documents! |
| EKG |
| Organ Donor Card |
|
|
Medical
History (including previous hospitalization, surgeries,
etcŠ)
|
| Date | Description |
| 1/1996 | Stroke |
| 2/1998 | Heart Condition |
| 6/2000 | Right coronary angioplasty. |
| 3/15/03 | Heart problems |
| 9/2003 | Double bypass surgery. |
Immunizations
|
| Date | Description |
| 4/1965 | Small pox |
| 5/23/1965 | Chicken Pox |
| 7/16/2000 | Tetanus/Mumps |
| 8/15/2000 | Flu |
Family
Medical History
|
| Relationship | Description |
| Mother | Breast Cancer |
| Father | Heart Disease |
| Brother | Brain Tumor |
Physicians
|
| Doctor | Specialty | Phone |
| Sue Marek, MD | Cardiologist | (713) 555-1793 |
| Mary Anderson, MD | Allergist Specialist | (713) 555-1255 |
| Joe Ottersbee, MD | Physician | (713) 555-1253 |
Emergency
Contact
|
| Name | Relationship | Phone (day) | Phone (night) | Phone (other) |
| Mary Jo Smith |
Neighbor |
(713) 555-1333 |
(713) 222-1414 |
|
| Beth Johnson |
Mother |
(713) 555-1258 |
|
|
| Mary M. Neighbor |
Friend |
(713) 555-1212 |
(281)867-5309 |
|
|
Medical/Health
Insurance Company
|
| Company | Group# |
ID# |
Phone |
| State Farm |
10943 |
345-34-6543 |
1-800-ALL-STAT |
Advance
Directives
|
| Organ Donor: |
No | Living Will: |
No |
| Other: |
Other comments here. |
Additional
Comments
|
| Patient travels extensively. Immediately contact Dr. Sue Marek for further information on Heart condition. |
