1.)Be an active member of your health care team (ensure you are fully aware of what is going on, why treatments are being done, know the risk involved in treatments and ask about alternative treatments.
2.)Ensure that your MD is aware of all medications you are taking including OTC meds.
3.)Ensure you know what, why, when and how you are to take a medication and know the side effects to watch for.
4.)Ensure that your MD is aware of any allergies (drugs, foods, etc) and reactions.
Patient Information Sheet
Mrs. Wanita Inform Yu
DOB 7/25/1958
713 Terryland Dr.
Los Angeles, California 79475
Medical History: Anxiety 1983, Hypertension 1994
Surgical History: Right lower leg fracture repair 1982 from a car accident.
Medical Doctors:
1. Dr Rilly Listens (Psychiatrist) Treatment of Anxiety 214-555-6666
2. Dr. Tue Fass (Primary Care) Treatment of Hypertension 214-777-8888
3. Dr. Kutt Meeh (Orthopedics) Surgery on R leg Fracture 214-999-1111
Family History: Mother and father suffer from Hypertension
Allergies (food, drug, contact, etc): Shell fish (Hives, swollen face, difficulty breathing.)
Current Medications:
1. Inderal 40mg one tablet every day by mouth for Hypertension.
2. Xanax 1mg one tablet every 4-6 hours as needed for Anxiety.
3. Ginko Biloba 1000mg one tablet every day for memory.
Other Important Information: Transfusion reaction 1982 (Broke out into a rash).
Contacts (Spouse, Family, Friends):
1. John Yue (husband) 214-234-5555
2. Susie Yue (daughter) 214-234-6666
3. Sandy Face (friend) 214-234-7777
Fill in your own information.
Keep this in your wallet or purse so that if something happens to you, the paramedics will be able to tend to you properly. Having this info with you could save your life.
Given to me by my classmate:
Shawn Bannister
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