Medication
Dosage
Frequency
| · |
No known medical conditions |
| · |
Abnormal EKG |
| · |
Adrenal Insufficiency |
| · |
Angina |
| · |
Asthma |
| · |
Bleeding Disorder |
| · |
Cancer |
| · |
Cardiac Dysrhythmia |
| · |
Clotting Disorder |
| · |
Coronary Bypass |
| · |
Dementia......Alzheimers |
| · |
Insulin Dependent |
| · |
Eye Surgery |
| · |
Glaucoma |
| · |
Hearing Impaired |
| · |
Heart Value Prosthesis |
| · |
Hemodialysis |
| · |
Other______________________________ |
Medical Conditions (check)
| · |
Hemolytic Anemia |
| · |
Hepatitis-Type [ ] |
| · |
Hypertension |
| · |
Hypoglycemia |
| · |
Leukemia |
| · |
Lymphomas |
| · |
Memory Impaired |
| · |
Myasthenia Gravis |
| · |
Pacemaker |
| · |
Renal Failure |
| · |
Seizure Disorder |
| · |
Sickle Cell Anemia |
| · |
Stroke |
| · |
Tuberculosis |
| · |
Vision Impaired |
| · |
Aspirin |
| · |
Barbiturate |
| · |
Codeine |
| · |
Demerol |
| · |
Horse Serum |
| · |
Insect Stings |
| · |
Latex |
| · |
Lidocaine |
| · |
Morphine |
| · |
Novocaine |
| · |
Penicillin |
| · |
Sulfa |
| · |
Tetracycline |
| · |
X-Rays Dyes |
| · |
No Known |
| · |
Environmental |
| · |
Other_________________ |
Allergies (check)
Living will on file (where):
EMS-NO CPR Directive or DNR Form (if yes,where):
Religion: