Medical Information Allergies: Indicate the type of prior reaction with an for mild reactions and an for potentially lethal “M” “L” reactions. (Note: If you create a replaces for lethal reactions and replaces for Smart911 profile, ‘*’ ‘L’ ‘√’ ‘M’ mild reactions in this section.) Aspirin Insect Stings Penicillin Codeine Latex Sulfur Demerol Lidocaine X-ray dyes Food Allergies Morphine Horse Serum Novocaine Other allergies: Breathing problems: Asthma Congenital/chronic upper Cystic fibrosis COPD airway disease Emphysema Other breathing problems: Cancer: Leukemia Lymphomas cancer: Catheters & feeding tubes: Feeding tubes Intravenous lines Foley catheter Medication port If use any of the above, how frequently do these supplies require replacement? Daily weekly monthly 2 times/week every other week General Medical Conditions: Adrenal insufficiency Glaucoma Renal failure/hemodialysis Alcoholism Hemophilia Rheumatologic/ Blood clotting–disorder Hypertension joint problems Chronic pain Malignant hypertension Sickle cell anemia Depression Malignant hyperthermia Situs inverse Diabetes Muscular dystrophy Stroke Eye surgery Myasthenia gravis Suicide attempt
Medical Information Allergies: Indicate the type of prior reaction with an “M” for mild reactions and an “L” for potentially lethal reactions. (Note: If you create a Smart911 profile, ‘*’ replaces ‘L’ for lethal reactions and ‘√’ replaces ‘M’ for mild reactions in this section.) Aspirin Codeine Demerol Food Allergies Horse Serum Insect Stings Latex Lidocaine Morphine Novocaine Penicillin Sulfur X-ray dyes Other allergies: Breathing problems: Asthma COPD Congenital/chronic upper airway disease Cystic fibrosis Emphysema Other breathing problems: Cancer: Leukemia Lymphomas cancer: Catheters & feeding tubes: Feeding tubes Foley catheter Intravenous lines Medication port If use any of the above, how frequently do these supplies require replacement? Daily 2 times/week weekly every other week monthly General Medical Conditions: Adrenal insufficiency Alcoholism Blood clotting–disorder Chronic pain Depression Diabetes Eye surgery Glaucoma Hemophilia Hypertension Malignant hypertension Malignant hyperthermia Muscular dystrophy Myasthenia gravis Renal failure/hemodialysis Rheumatologic/ joint problems Sickle cell anemia Situs inverse Stroke Suicide attempt
EMI-form.docx