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| Asthma |
| Diabetes
Types |
| High
Blood Pressure |
| Epilepsy |
| Heart
Valve |
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Name
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Dosage
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Frequency
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Purpose
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Glucotrol
XL
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5
mgm
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1
Daily
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Diabetes
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Hyzaar
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100/25
mg
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1
Daily
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High
Blood Pressure
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| Contacts |
| Retainer |
| Hearing
Aid |
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3/14/2006
Wart on finger
Treating Physician: Dr. Paul Smith
Right index finger wart burnt off.
3/10/2006
Office Visit
Treating Physician: Dr. Tim Anderson
Height: 6'2"
Weight: 233lbs.
Blood Pressure: 120/70
Pulse: 68
Blood sugar levels checked.
Findings - normal to border line high range.
Doctor recommended:
Diet: 1250 calories per day.
Walking 30 minutes daily.
Revisit schedued for 6/9/2006.
Labs to be done before next office visit.
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| Date
of Birth (mm/dd/yyyy) |
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Primary
(November 15th - April 15th)
4565 Palm Lane
Unit B4
Somewhere, FL 00000
USA
555-555-1212 Home
555-555-1313 Cell
555-555-1515 Fax
joe@medfn.com
Secondary
(April 16th - November 14th)
123
Main Street
Apt A
Anywhere, FL 12345
USA
555-555-1414 Home
joe@medfn.com
Mailing
P.O. Box 1
Anywhere, DC 12345
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Primary
Dr. Paul Smith - General Practitioner
Main Street Clinic North
987 Primary Rd.
Suite 1
Any Town, DC 12345
555-555-1111 Office
555-555-2222 Fax
drsmith@medfn.com
Specialist
Dr. Tom Hart - Cardiologist
Center City Hospital
1 Hospital Lane
Any Town, DC 12345
555-555-3333 Office
555-555-4444 Cell
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Primary
Jane Doe - Wife
123 Main Street
Any Town, FL 12345
555-555-1234 Home
555-555-4321 Work
555-555-2345 Cell
jdoe@medfn.com
Secondary
Mary Doe - Sister
456 Main Street
Any Ttown, FL 12345
555-555-5678 Home
555-555-8765 Cell
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Medicare
John Anthony Doe
000-00-0000-A
Male
Effective Date: Hospital (Part A) 01/01/2002
Effective Date: Medical (Part B) 01/01/2002
Effective Date: Prescription (Part D) 01/01/2006
Secondary
Prime Plan Insurance Co.
Medicare Supplement Plan F
Policy # 123456789
800-555-3434 Main
800-555-9999 Claims
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Living
Will:
I
have designated, as my surrogate to carry out the provisions
of my living will.
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Jane
Doe - Wife
123 Main Street
Any Town, FL 12345
555-555-1234 Home
555-555-4321 Work
555-555-2345 Cell
jdoe@medfn.com
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Please do not donate my organs
for scientific experiments.
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