A B O U T M E A B O U T M E. I n t h i s s e c t i o n, y o u w i l l f i n d : Your important contacts. Your medical history
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1 A B O U T M E A B O U T M E I n t h i s s e c t i o n, y o u w i l l f i n d : Your important contacts Your medical history A place to list your medications A place to write down your questions A calendar for your appointments
2 M y P e r s o n a l I n f o r m a t i o n My name is... My chart Number... My contact information Address... City... Province... Postal Code... Home Phone... Cell Phone... My emergency contacts Name... Relationship... Home Phone... Cell Phone... Name... Relationship... Home Phone... Cell Phone... 2
3 M y H e a l t h c a r e T e a m You will be working with several different healthcare professionals during your cancer care. Here is a place where you can keep track of their names and contact information. A description of what each healthcare provider does can be found in the Just diagnosed tab. London Regional Cancer Program Automated Service Press 2 to change appointments Press 3 to speak to a telephone triage nurse Press 0 to speak to an operator LRCP Pharmacy: Canadian Cancer Society Volunteer Drivers: Supportive Care: Surgical oncologist Name... Medical oncologist Name... (Chemotherapy doctor) Primary clinic nurse Name... Name... Radiation oncologist Name... (Radiation doctor) Primary radiation nurse Name... Name... Radiation therapist(s) Name... Name... Name... 3
4 My supportive care team Dietitian Name... Social worker Name... Spiritual care specialist Name... Other specialist Name... Community Care Access Centre CCAC Phone #... Case Manager Other hospital clinic Name... Phone #... Pharmacy/drugstore Name... Phone #... Address... A... A... Family doctor Name... Phone #... Address... A... A... You may have other important contacts that you would like to record. You can write this information here: Name... Phone # Name... Phone #
5 M y M e d i c a l H i s t o r y My Allergies Write down your allergies (including drug, food, and other allergies) and your reaction (e.g. rash, fever, hives, swelling). Allergy Reaction My medical conditions (include both past and present): Arthritis Asthma Depression Diabetes Heart disease Kidney disease Liver disease Migraines Seizures Stroke High blood pressure Other... Notes
6 M y M e d i c a t i o n s These pages will help you keep track of the medications you are taking. Bring this list of medications with you each time you come to the cancer centre. This will help to make sure that you are not given a new medication that is not safe for you to take. Be sure to include all of your medications, including prescription medications, over-the-counter medications, herbal supplements and vitamins. If you have allergies or react to certain medications, tell your doctor, nurse or pharmacist. Your pharmacist may give you a medication calendar to help you remember when to take your cancer medicine. Keep your medication calendars in this section of your binder. Keep this list up-to-date and bring it with you to all of your appointments. Example: Atorvastatin (Lipitor) High Cholesterol 2/23/12 10 mg 1 tablet in the afternoon Makes me feel tired. 03/01/12. 6
7 MY M e d i c a t i o n s 7
8 MY M e d i c a t i o n s 8
9 MY M e d i c a t i o n s 9
10 MY M e d i c a t i o n s 10
11 MY Q u e s t i o n s ed By ed By ed By ed By ed By ed By 11
12 MY Q u e s t i o n s ed By ed By ed By ed By ed By ed By 12
13 MY C a l e n d a r 13
14 14 MY C a l e n d a r
Pediatric Patient History
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Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:
5002 Highway 39 N Bldg. A Meridian, MS 39301 Phone: 601-512-0500 Fax: 601-512-0505 Patient Information Patient: Gender: Male Female First Middle Last Primary Language: English Spanish Other Mailing Address:
R. B. KO L A C H A L A M M. D. GENERAL SURGERY
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MICHELE S. GREEN, M.D.
MICHELE S. GREEN, M.D. Name Last First Middle initial Address Number Street Apt# City, State Zip Home Cell Email Please Circle: Preferred Contact Number Home Cell Work Single Married Divorced Widowed Male
Iowa (ACS, 2008) 14.2% Lisa Scott Sonia Ryang. Henny Ohr. Iowa. Iowa. Iowa: Nara Chea. Lorna Hines & Tom Baccam
2012 - Khmer 52,597 Iowa 2010 4 10% Iowa2001 27.6 37.6 (US census, 2000) $53,431 $5,000 Iowa (ACS, 2008) 14.2% Iowa Iowa Des Moines 2010 2012 IowaIowa Lisa Scott Sonia Ryang Iowa Henny Ohr Iowa Iowa Iowa:
PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
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DAHIYA FACIAL PLASTIC SURGERY AND LASER CENTER CONSULTATION AND MEDICAL HISTORY. Name Date of Birth Today s Date Address: Street City State Zip
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