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  • Historia Clinic A Cancer

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    fredavilamolina17
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    This document contains personal medical information including the individual's name, date of birth, social security number, address, phone numbers, emergency contacts, insurance information, medical history of surgeries, conditions, allergies, current medications, and cancer diagnosis details if applicable. The information is organized into sections covering identity, family contacts, insurance coverage, medical profile, cancer details, and treatments.

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    Historia Clinic a Cancer

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    This document contains personal medical information including the individual's name, date of birth, social security number, address, phone numbers, emergency contacts, insurance information, medical history of surgeries, conditions, allergies, current medications, and cancer diagnosis details if applicable. The information is organized into sections covering identity, family contacts, insurance coverage, medical profile, cancer details, and treatments.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as RTF, PDF, TXT or read online from Scribd
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    11 views6 pages

    Historia Clinic A Cancer

    Uploaded by

    fredavilamolina17
    This document contains personal medical information including the individual's name, date of birth, social security number, address, phone numbers, emergency contacts, insurance information, medical history of surgeries, conditions, allergies, current medications, and cancer diagnosis details if applicable. The information is organized into sections covering identity, family contacts, insurance coverage, medical profile, cancer details, and treatments.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as RTF, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 6

    MY HISTORY MY INFORMATION

    Name Date of Birth Social Security # Address City State !i" Home #ho$e %or& #ho$e Cell #ho$e Fa' ()mail

    MY FAMI*Y CONTACTS
    IN TH( (+(NT OF AN (M(R,(NCY TH( FIRST #(RSON TO CONTACT ISName Relatio$shi" Address City State !i" Home #ho$e %or& #ho$e Cell #ho$e Fa' ()mail TH( S(COND #(RSON TO CONTACT ISName Relatio$shi" Address City State !i" Home #ho$e %or& #ho$e Cell #ho$e Fa' ()mail

    MY HISTORY MY INS.RANC( CO+(RA,(


    (Remember to bring your insurance cards every time you see a new doctor.) #RIMARYName of I$sured Com"a$y Name Address City State !i" Tele"ho$e Fa' #olicy Num/ers Social Security # of I$sured

    S(CONDARYName of I$sured Com"a$y Name Address City State !i" Tele"ho$e Fa' #olicy Num/ers Social Security # of I$sured

    MY M(DICA* #ROFI*(
    S.R,(RI(STy"e of Sur0ery Date Hos"ital Reaso$ for Sur0ery

    MY HISTORY MY M(DICA* #ROFI*( 1CONTIN.(D)


    M(DICA* CONDITIONS- (For example: high blood pressure, heart trouble, diabetes, depression, breathing problems, other) Co$ditio$ Year Dia0$osed Ho2 Is it Treated

    A**(R,I(S- (For example: medications, food, and/or other substances) Aller0y Aller0ic Reactio$ 1%hat sym"toms de3elo"45

    M(DICATION I TA6(nformation the doctor will want to !now for each medication: "hy are you ta!ing it# $ow long have you been ta!ing it# "hat is the dosage# $ow many times a day do you ta!e the medication# ( f you are not sure, bring the medication with you.) Medicatio$ Dose Num/er of Times Date Started #rescri/ed By Ta&e$ #er Day

    MY HISTORY MY M(DICA* #ROFI*( 1CONTIN.(D5


    OTH(R M(DICATION I TA6(Remember to include on your list any over the counter (%&') medicine you ta!e (vitamins, herbs, pain relievers, supplements, etc.). Other Medicatio$ Dose Num/er of Times Ta&e$ Date Started #er Day

    OTH(R INFORMATION TO SHAR( %ITH MY H(A*TH)CAR( T(AM-

    MY HISTORY
    MY CANC(R DIA,NOSIS Date of Sur0ery or Bio"sy Doctor #lace #rocedure %as #erformed Sur0ery That %as #erformed Results of My Sur0ery #rimary Ca$cer Ty"e Ty"e of Tumor 1Histolo0ical Ty"e5 Sta0e of Disease A$y #ro/lems Si$ce My Sur0ery OTH(R INFORMATION-

    TR(ATM(NTS-

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