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Patient Guide - Information sheets


Goldstec

Information sheets to help you prepare for your trip to the ER or to a new medical practice.

The pdfs of these sheets can be downloaded here Patient Guide - medical trips.pdf for easy printing.

Medications - current

Name                    dosage              prescribed by                     to treat what symptom

 

 

 

 

 

 

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NOTES:  allergies and notes about reactions to meds should be detailed here.








Medical History:

Illnesses:  (be sure to include when you had the illness, treatment for the illness and whether you completely recovered or are still being treated for this illness)









 

Surgeries:  (date, what the surgery treated, was it successful or not? If not, what lasting complications, if any)










Specific test ranges or numbers - standard to you.  
HR range:

BP range:





 

Doctor or medical professional most familiar with your illness

Name__________________________________

Email Address______________________________________

Phone__________________________

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