• 

Organ Donor

This is an example of the information emergency personnel see upon entering a member’s name and Member ID into the 1st Responder page.

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 – Religion

  Married – Protestant

• Gender – Birth Year – Blood

  Female – 1975 – AB+

• Height – Weight – Hair Color – Eye Color

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

   

Medical 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

   

• Name:

  Mary Smart

• Relationship / Contact Type

  Relative

• Telephone

  +1-444/444-1233

• Alternate Telephone

  +1-666/444-1212

• Work Telephone

  +1-555/555-1555

   

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

   

Medications

• Medication:

  Hydrochlorothiazide (Microzide)

• Dosage / Frequency

  50 MG   –   daily

   

• Medication:

  Allopurinol  

• Dosage / Frequency

  300 mg   –   daily

   

Allergies

• ASTHMA-HAY FEVER / Pollen

• Reactions

  Sinus reaction to pollen, difficulty breathing on windy days in spring.

• Notes

  Take antihistamines.

   

• DRUG / Penicillin

• Reactions

  Allergic reaction with rash, hives and difficulty breathing.

• Notes

  This lasts three to five days.

   

• FOOD / Mushrooms

• Reactions

  Rash that covers entire body, itching with soreness.

• Notes

  The more mushrooms the worse the reaction. Resembles measles.

•  

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

   

Surgeries & Procedures

• Surgery:

  Biopsy   Colonostomy 

• Surgeon / Surgery Date

  Harold Rogers   3 / 4 / 2018 

• Facility Name

  Gastroenterology Center   –   Surgery Center

• Telephone

  - 555/555-1212

 

• Surgery:

  Biopsy   Subcuetaneous Cyst Removal 

• Surgeon / Surgery Date

  Gerald Franklin   4 / 4 / 2009 

• Facility Name

  North Dallas Center   –   Out-patient

• Telephone

  - 555/555-1212

 

Physicians

• Physician Name:

  James Redding, MD,  –  Primary

• Specialty

  General Practitioner   Internal Medicine

• Telephone / Alternate

  +1-555/555-1212   +1-555/555-1212

•  

• Physician Name:

  Marissa Jennings, MD

• Specialty

  Dermatologist   Reconstructive Surgery

• Telephone / Alternate

  +1-555/555-1233   +1-555/333-123

•  

Vaccinations

• Immunizations

  Influenza – 3/8/2018

•  

  Shingles Herpes/Zoster – 5/17/2017

•  

  Shingrix (1st dose) – 7/20/2019

•  

  Shingrix (2nd dose) – 10/5/2019

•  

  Hepatitis A – 5/17/2009

•  

  Hepatitis B – 5/17/2009

•  

  Pneumovax (PPSV 23) – 4/21/2005

•  

  Prevnar (PCV 13) – 5/12/2019

•  

  Tetanus/Diphtheria (Td) – 5/15/2002

•  

  Tetanus/Diphtheria/Pertussis (Tdap/DTaP) – 6/5/2007

•  

  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

• 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