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View Member’s Medical Records Example

This is an example of the information emergency personnel see upon entering a member’s name and Member ID into the EMERGENCY LOGIN. Also see Medical / Mental Alert Examples and Member’s example under Visitors.

PERSONAL AND MEDICAL CONTACTS AND CONDITIONS

 

Personal Data

 

  • Member ID:

  • Name:

    Lynn Smart

  • Address:

    3333 Center Street, #423

  • City/State/Zip/Country

    Dallas, TX 85204 – USA

  • Telephone

    +1-555/555-1212

  • Alternate Telephone

    +1-555/555-1214

  • Martial – Race – Blood Type – Gender

    Married – Latino – Hispanic – AB+ – Female

  • Height – Weight – Hair Color – Eye Color

    5 ft.' 3 in.''– 132 lbs. lbs. – Black – Brown

     

Organ Donor

  • I am an Organ Donor:

    Yes

  • Donor Organization or Service:

    Southwest Transplant Alliance

  • Location of Donor Service:

    Texas USA

  • Organ Donor Notes:

    Registered online in 2013 at www.organ.org Southwest Transplant Alliance.

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Emergency Contacts

  • Name:

    Allen Smart

  • Relationship / Contact Type

    Spouse

  • Telephone

    +1-555/555-1212

  • Alternate Telephone

    +1-555/555-1213

  • Work Telephone

    +1-555/555-1445

     

  • Name:

    Mary Smart

  • Relationship / Contact Type

    Relative

  • Telephone

    +1-444/444-1233

  • Alternate Telephone

    +1-666/444-1212

  • Work Telephone

    +1-555/555-1555

     

Physicians

  • Physician Name:

    James Redding, MD,  –  Primary

  • Specialty

    General Practitioner   Internal Medicine

  • Telephone / Alternate

    +1-555/555-1212   +1-555/555-1212

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  • Physician Name:

    Marissa Jennings, MD

  • Specialty

    Dermatologist   Reconstructive Surgery

  • Telephone / Alternate

    +1-555/555-1233   +1-555/333-123

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Medications

  • Medication:

    Hydrochlorothiazide (Microzide)

  • Dosage / Frequency

    50 MG   –   daily

     

  • Medication:

    Allopurinol  

  • Dosage / Frequency

    300 mg   –   daily

     

Allergic Reactions

  • Drug Allergies

    Asprin | Demerol Iodine | Flagyl | Morphine | Sulfa

  • Food Allergies:

    | Milk | Peanuts

  • Food Allergy Notes:

    Lactose Intolerant

     

  • Asthma / Hay Fever Allergies:

    Asthma | Mold | Dander

  • Asthma / Hay Fever Notes:

    Congestion, watery eyes and sneezing

     

  • Other Allergy Notes:

    Severe reaction to wasp stings

     

Medical Conditions

  • Medical Condition:

    Hypertensive heart disease 1 1

  • Last Treated:

    5 / 19 / 2017

     

  • Medical Condition:

    Barrett's Esophagus 5 1

  • Last Treated:

    9 / 5 / 2013

     

Surgeries & Procedures

  • Surgery:

    Biopsy   Colonostomy 

  • Surgeon / Surgery Date

    Harold Rogers   3 / 4 / 2018 

  • Facility Name

    Gastroenterology Center   –   Surgery Center

  • Telephone

    +1 - 555/555-1212

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  • Surgery:

    Biopsy   Subcuetaneous Cyst Removal 

  • Surgeon / Surgery Date

    Gerald Franklin   4 / 4 / 2009 

  • Facility Name

    North Dallas Center   –   Out-patient

  • Telephone

    +1 - 555/555-1212

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Recent Treatments

  • Condition Treated:

    Joint Pain  

  • Practitioneer / Treatment Date

    Brad Carlston   –   3 / 5 / 2018

  • Facility Name

    Carlston Chiropractic   –   Chiropractic Adjustment

     

  • Condition Treated:

    Muscle Soreness  Neck Stiffness

  • Practitioneer / Treatment Date

    Annie Petrolli   –   7 / 17 / 2017

  • Facility Name

    Health North   –   Physical Therapy

     

Vaccinations

  • Immunizations

    Influenza – 3/8/2018

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    Shingles Herpes/Zoster – 5/17/2017

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    Hepatitis A – 5/17/2009

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    Hepatitis B – 5/17/2009

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    Pneumovax – 4/21/2005

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    Tetanus – 5/15/2002

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    Human Papillomavirus – 7/24/2014

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    Vericella/VZV – 4/8/2016

     

  • Age Related Immunizations:

    Childhood vaccinations during the 1980s

     

  • Travel Related Immunization Notes:

    Hepatitis A & B, Tetanus, Polio, Typhoid and Malaria pills, plus Yellow Fever for visiting Gorillas in Central Africa

     

  • Other Immunization Notes:

    I have an allergic reaction to synthetic tetanus

     

Your Health Insurance / Perscription Coverage Data

  • Insurance Company

    Unity Medical Care   –   Primary Health Plan

  • Plan Name

    Silver Health

  • Policy Members

    Lynn Smart / Allen Smart

  • Consumer / Provider Telephone

    +1 - 888 / 555 - 1222   /   +1 - 800 / 555 - 1212

     

  • Insurance Company

    Foremost Dental Health   –   Dental Plan

  • Plan Name

    Smile One

  • Policy Members

    Lynn Smart / Allen Smart

  • Consumer / Provider Telephone

    +1 - 555 / 555 - 1212   /   +1 - 555 / 555 - 2222