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Individual Information Profile
General Profile
General Conact Information:
First Name(s): Steve, Steven, Steven, Skip, S
Middle Name(s): L, Lee
Last Name(s): Klinger
Home Phone: 555-555-3567 Celular Phone: 555-555-9876
eMail: sklinger@xxx.com
Address: 113 Lake View Dr., Mytown, CA, 92117, USA
General Attributes
Race: Caucasian
Sex: Male
Birthdate: 4/21/1950 Age: 65 (calculated)
Height: 5'11"" (180 cm calculated)
Weight: 175 lbs (80 Kg calculated)
General Instructions: Can become confused and needs to be sat down and talk about his house.
Steve K.
65 Years Old
5'11", 165 lbs
Conditions:
- Allergies (Penicilin, Bees)
- Type 2 Diabetic
No
Picture
Available
Individual Profile and Emergency Information(for Steve Klinger System Nickname: Jill's Home)
Medical Contact Information
Medical Contact Informtion:
Contact 1:
Name: Type: Primary Care Physician Emergency:
Health Network(s)
Contact 1:
Steven Klinger
65 Years Old
5'11"
165 lbs
Conditions:
- Allergies (Penicilin, Bees)
- Type 2 Diabetic
Public Saftey/Medical View
Active
Public Alternate View
Not Active
Primary Medical Record # AQR1234568PT
Medicines:
- Insulin
Contacts:
- Jill 619-555-1234 (US) Jill@hotmail.com - Daughter
- Jon 858-555-4321 (US) jonp@gmail.com - Power of Atrny
- Dr Joe Smith 619-555-1243 - Primary Physician
Primary Insurance: HealthcareNet Toll Free 888-555-1234, or 303-555-1243 Collect
Steven Klinger
- Single White Male
- 65 Years Old
- 5'11" 165 lbs
Conditions:
- Allergies (Penicilin, Bees)
- Type 2 Diabetic
- Has partial Alzheimer's
Public Primary View
Active
Medical Information
General Health: Good
Conditions: Diabetic, Early Alzheimer's, can't walk more than a mile
Allergies: Bees (anaphylaxis)
Other Physical Reactions: Codeine, sugar, needles
Prescribed Medications: Insulin
Other Medications: EpiPen® (epinephrine)
Special Instructions: All care needs to be coordinated through primary contacts, as he does not always understand what is happening.
Do Not Resuscitate Agreement: None
Organ Doner Agreement: None
Public Identity Profiles (visible on Identity Tag Camera/RFID Scan)
Insurance Information
Insurance Contacts:
Primary
Secondary
Emergency Contacts
Personal and Guardian Contacts:
Emergency Contact 1:
Name: Jill Davis Relationship: Daughter Phone 1: Phone 2:
Address: Email:
Authorizations: Power of Attorney
Notes:
Emergency Contact 2:
Name: Jon Pesco Relationship: Neighbor/Friend Phone 1: Phone 2:
Address: Email:
Authorizations: None
Notes:
Organization Contacts
Valley View Retirement Home Relationship: Phone 1: Phone 2:
Address: Email:
Authorizations: None
Notes:
Alzheimer's - Anytown Chapter Relationship: Phone 1: Phone 2:
Address: Email:
Authorizations: None
Notes:
