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
Heart Disease: Aortic aneurysm Angina Cardiac dysrhythmia (abnormal heart rate) Congenital heart failure Congestive Heart Failure (CHF) Coronary artery bypass/angioplasty History of heart attack/Myocardial infarction History of myocarditis/Pericarditis/ heart infection Pulmonary hypertension Mobile Limitations: Amputee Confined to bed Electric wheelchair or scooter Manual wheelchair Paraplegia Quadriplegia Require walker, cane, or crutches Require wheelchair Weight over 300 pounds Other mobility impairment: Neurological, Behavioral, Cognitive Conditions: Anxiety (extreme) Autism spectrum disorder Bipolar disorder Cerebral Cognitive impairment Confused easily Developmental disability Developmentally delayed Difficulty understanding verbal or written instructions Intellectual Disability Memory impaired, dementia, Alzheimer’s Migraine or frequent headaches Neurological disease PTSD Prone to wandering Seizure disorder/epilepsy Schizophrenia Other psychiatric conditions: Organ transplants: Bone marrow Bowel Heart Kidney Liver Lung Pancreas Powered Medical Devices: Apnea monitor IV pump Kidney dialysis Life sustaining medication requiring refrigeration Nebulizer for breathing problems Oxygen concentrator Sleep apnea, CPAP, BRAP device Ventilator/Respirator Other life-sustaining device or equipment dependent on electricity: Prescription Medications:
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: