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Member Profile Summary Example

This is an example of the categories and the information that a member can enter into the forms within their secure profile. Only a member can access and enter information into their secure profile. Also see, Medical Alert Example.
View an emergency profile example of the information that First Responders see.

PERSONAL AND MEDICAL CONTACTS AND CONDITIONS

 

Personal Data

 

  • 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

     

Medical / Mental Alert

  • Personal Item Alert:

    I have an external pacemaker.  

     

    I have an AICD.

     

    I wear contact lenses.

     

  • Medical Alert Condition:

    Medical Alert
    Please be advised that Lynn Smart suffers from Type 1 Diabetes

  • Medicine

    Glulisine (Apidra)

  • Contact / Telephone

    Allen Smart / +1-555/555-1212

  •  

  • Mental Alert Condition:

    Mental Health Alert
    Please be advised that Lynn Smart suffers from Depression

  • Medicine

    Citalompram HBR

  • Contact / Telephone

    Allen Smart / +1-555/555-1212

  • Alert Note

    Suffers from mild to severe depression

  • Mental Health Emergency Directive

    Mental Health Alert
    Lynn Smart suffers from a mental illness. If first responders have been summoned due to a disturbance, complaint or irrational activity, please take this into consideration when dealing with this person.

  • Facility Directive

    Please take this person to the following mental health facility:
    Green Haven MH Hospital

  •  

  • Medical Alert Condition:

    Medical Alert
    Please be advised that Lynn Smart suffers from Rare Blood Type

  • Alert Note

    I have type AB+ but have an additional condition.

  •  

  • Medical Alert Condition:

    Medical Alert
    Please be advised that Lynn Smart suffers from Deafness

  • Alert Note

    I must use American Sign Language to communicate.

  •  

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.

  •  

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

  • Email

    michael@mcgrathdesign.com

  • Address:

    Hilton Shores Estate, 2552 Wentworth Ave.

  • City/State/Zip/Country

    Dallas, TX 75248 – USA

     

  • Name:

    Mary Smart

  • Relationship / Contact Type

    Relative

  • Telephone

    +1-444/444-1233

  • Alternate Telephone

    +1-666/444-1212

  • Work Telephone

    +1-555/555-1555

  • Email

    michael@mcgrathdesign.com

  • Address:

    3333 Elm Street, #204

  • City/State/Zip/Country

    Dallas, TX 75204 – USA

     

Physicians

  • Physician Name:

    James Redding, MD,  – Primary

  • Specialty

    General Practitioner,  Internal Medicine

  • Telephone

    +1-555/555-1212

  • Alternate Telephone

    +1-555/555-1212

  • Address:

    Medical City, 4500 Clark Street, # 520

  • City/State/Zip/Country

    Dallas, TX 75248 – USA

     

  • Physician Name:

    Marissa Jennings, MD

  • Specialty

    Dermatologist,  Reconstructive Surgery

  • Telephone

    +1-555/555-1233

  • Alternate Telephone

    +1-555/333-123

  • Address:

    4218 Park Blvd., Suite 110

  • City/State/Zip/Country

    Plano, TX 75024 – USA

     

Medications

  • Medication:

    Hydrochlorothiazide (Microzide)

  • Prescription # / Expiration Date

    34455323   –   5 / 2018

  • Dosage / Frequency

    50 MG   –   daily

  • Pharmacy Name

    SuperT

  • Telephone

    +1-555/555-1234

  • Address:

    Pleasant Hills Center, 4650 Highline Drive

  • City/State/Zip/Country

    Dallas, TX 75248 –

  • Notes:

    Assist in reducing salt absorption

     

  • Medication:

    Allopurinol  

  • Prescription # / Expiration Date

    6246192   –   9 / 2018

  • Dosage / Frequency

    300 mg   –   daily

  • Pharmacy Name

    CVWalco

  • Telephone

    +1-555/555-1212

  • Address:

    Rolling Mills Shopping Center, 3320 Ravenswood Rd. #231

  • City/State/Zip/Country

    Dallas, TX 75248 –

  • Notes:

    Control Uric Acid

     

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

  • Taking Medication as Treatment:

    yes

  • Notes:

    Have reduced salt intake and ceased alcohol; on low-fat diet and exercise regularly to acheive weight loss. To date I have lost 32 pounds; non-smoker.

     

  • Medical Condition:

    Barrett's Esophagus 5 1

  • Last Treated:

    9 / 5 / 2013

  • Taking Medication as Treatment:

    yes

  • Notes:

    No displasia in the esophagus

     

Surgeries & Procedures

  • Surgery:

    Biopsy  Colonostomy

  • Surgeon / Surgery Date

    Harold Rogers   –   3 / 4 / 2018

  • Facility Name

    Gastroenterology Center   –   Surgery Center

  • Telephone

    +1-555/555-1212

  • Address:

    366 Midway Road, Suite 23

  • City/State/Zip/Country

    Dallas, TX 75248 – USA

  • Notes:

    Routine checkup with removal of two very small polyps - return in three years

     

  • 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

  • Address:

    Trinity Shopping Center, 3222 Hillsdale Avenue

  • City/State/Zip/Country

    Dallas, TX 75287 – USA

  • Notes:

    No existing evidence of carcinoma after procedure - test came back negative.

     

Recent Treatments

  • Condition Treated:

    Joint Pain  

  • Practitioneer / Treatment Date

    Brad Carlston   –   3 / 5 / 2018

  • Facility Name

    Carlston Chiropractic   –   Chiropractic Adjustment

  • Telephone

    +1-555/222-5321

  • Address:

    4550 Inverness Way, #365

  • City/State/Zip/Country

    Addison, TX 75248 – USA

  • Recent Treatment Notes:

    Treated hip that was slipping in socket - Adjustment was much more painful than I had anticipated. Went for four treatments and discontinued. Not presently having problem.

     

  • Condition Treated:

    Muscle Soreness  Neck Stiffness

  • Practitioneer / Treatment Date

    Annie Petrolli   –   7 / 17 / 2017

  • Facility Name

    Health North   –   Physical Therapy

  • Telephone

    +1-555/555-5577

  • Address:

    5524 Parker Lane

  • City/State/Zip/Country

    Dallas, TX 75004 – USA

  • Recent Treatment Notes:

    Nine session therapy for neck stiffness - inabiliity to turn head left or right.

     

Vaccinations

  • Immunizations

    Influenza – 3/8/2018

  •  

    Shingles Herpes/Zoster – 5/17/2017

  •  

    Hepatitis A – 5/17/2009

  •  

    Hepatitis B – 5/17/2009

  •  

    Pneumovax – 4/21/2005

  •  

    Tetanus – 5/15/2002

  •  

    Human Papillomavirus – 7/24/2014

  •  

    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

  • Subscriber Number / Group Number

    82919096D   /   401648

  • Policy Members

    Lynn Smart / Allen Smart

  • Insurance Card Number / Card Date

    3501890505276826   –   6 / 5 / 2018

  • Payer ID Number / Effective Date

    47626   –   6 / 5 / 2018

  • COPAY – O Visit/Spec OV/Urg Care/ER

    20 / 40 / 35 / 100

  • RX COPAY – Tier 1 / Tiew 2 / Tier 3

    10 / 35 / 60

  • Consumer / Provider Telephone

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

  • Health Insurance Notes:

    $10,000 deductible - max out of pocket $15,000

     

  • Insurance Company

    Foremost Dental Health   –   Dental Plan

  • Plan Name

    Smile One

  • Subscriber Number / Group Number

    343222   /   43332

  • Policy Members

    Lynn Smart / Allen Smart

  • Insurance Card Number / Card Date

    343232-ADA   –   5 / 7 / 2018

  • Payer ID Number / Effective Date

    34221D   –   5 / 7 / 2018

  • COPAY – O Visit/Spec OV/Urg Care/ER

    / / /

  • Consumer / Provider Telephone

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

  • Health Insurance Notes:

    Covers preventive care with $45 copay