Patient Medical Information Name Date of Birth (i.e. Jack Doe) (i.e. 05/05/1947) Doctors Last Next Name of Doctor Specialty Phone Number Appointment Appointment (i.e. August 5, 2014 (i.e. Dr. Jane Smith) (i.e. Cardiac) (i.e. April 3, 2014) (i.e. 517-555-4555) 1pm) Allergies/Sensitivities Allergy Type of Reaction (Drug Name) (i.e. Hives) Medications Name Route Dose Frequency (i.e. Lasix) (i.e. oral) (i.e. 20mg 1 tablet) (i.e. daily) Medical History Medical Condition Date Diagnosed Ongoing or Resolved (i.e. Congestive Heart Failure) (i.e. May 2005) (i.e. Ongoing) Surgeries Date of Surgery (i.e. Right Total Knee Replacement) (i.e. April 2004)
Patient Medical Information Name Date of Birth (i.e. Jack Doe) (i.e. 05/05/1947) Doctors Name of Doctor Specialty Last Appointment Next Appointment Phone Number (i.e. Dr. Jane Smith) (i.e. Cardiac) (i.e. April 3, 2014) (i.e. August 5, 2014 1pm) (i.e. 517-555-4555) Allergies/Sensitivities Allergy Type of Reaction (Drug Name) (i.e. Hives) Medications Name Route Dose Frequency (i.e. Lasix) (i.e. oral) (i.e. 20mg 1 tablet) (i.e. daily) Medical History Medical Condition Date Diagnosed Ongoing or Resolved (i.e. Congestive Heart Failure) (i.e. May 2005) (i.e. Ongoing) Surgeries Date of Surgery (i.e. Right Total Knee Replacement) (i.e. April 2004)
FINALHOME_HEALTH_EMERGENCY_PREPAREDNESS_PL_2FINAL_484106_7.docx