1st Responders Profile Example

    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 MEDICAL RECORDS AND CONTACTS

     

    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

       

    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

       

    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

    •  

    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

    •  

    • 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

    •  

    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

    •  

      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

    • 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