Antiarrhythmic Anti-psychotic Erectile dysfunction Anticoagulant/blood Anti-seizure medication thinner Beta blocker Immune suppressant Antihistamine (regular Chemotherapy Insulin use) Diabetes medication (oral) Narcotics (regular use) Antianginal Steroid (oral) prescription medication: Sensory Impairments (vision, hearing and speech) and Assistive Technology: Blind Hard of hearing Interpreter Deaf/blind Hearing aids Speech impaired Braille Batteries Nonverbal Computer Cochlear Implant Augmentative or iPad (external/removable parts Alternative communication Deaf of the C.I. system) Device Other Medical information: Glasses or contact lenses: Yes No Organ donor: Yes No Advance directive: Yes No If yes, where is it located? Hospital preference: Main Direct Care or Support person(s) Name/Number: Implanted Medical Devices: Artificial joints Left Ventricular Assist Device (LVAD) Cochlear implants(s) Pacemaker Heart valve prosthesis/artificial heart valve Tracheotomy Implanted defibrillator Insulin Pump Medical Therapies and Equipment: Home health care/visiting nurse/non-medical caregiver: Agency or Name/number: Home health care/Visiting nurse/Non-medical caregiver (around-the-clock): Agency or Name/number:
Antiarrhythmic Anticoagulant/blood thinner Antihistamine (regular use) Antianginal Anti-psychotic Anti-seizure Beta blocker Chemotherapy Diabetes medication (oral) Erectile dysfunction medication Immune suppressant Insulin Narcotics (regular use) Steroid (oral) prescription medication: Sensory Impairments (vision, hearing and speech) and Assistive Technology: Blind Deaf/blind Braille Computer iPad Deaf Hard of hearing Hearing aids Batteries Cochlear Implant (external/removable parts of the C.I. system) Interpreter Speech impaired Nonverbal Augmentative or Alternative communication Device Other Medical information: Glasses or contact lenses: Yes No Organ donor: Yes No Advance directive: Yes No If yes, where is it located? Hospital preference: Main Direct Care or Support person(s) Name/Number: Implanted Medical Devices: Artificial joints Cochlear implants(s) Heart valve prosthesis/artificial heart valve Implanted defibrillator Left Ventricular Assist Device (LVAD) Pacemaker Tracheotomy Insulin Pump Medical Therapies and Equipment: Home health care/visiting nurse/non-medical caregiver: Agency or Name/number: Home health care/Visiting nurse/Non-medical caregiver (around-the-clock): Agency or Name/number:
EMI-form.docx