Medical Info

David Sample

Medical Alerts / Conditions:

Type 2 Diabetes Heart Surgery -4 Stents (DOS 23 Sept 1996) Head plate inserted (DOS 20 May 1998)

COVID-19

COVID-19 tested?: () Yes( ) No

Result: ( ) Positive() Negative

Date of test:

COVID-19 Vaccinated?:() Yes( ) No

COVID-19 Vaccination Date:

Medical (RX) Presciptions:

Metformin 500 MG Glipizide 20MG

Non Prescribed Drugs, Medications, Supplements:

Olive oil

Allergies:

Ragweed Iodine

Blood Type:

Blood Type: OB Positive

Other Important Info:

Anxiety

Emergency Contact - 1:

Name: Sample

Phone: 555-555-5555

Emergency Contact - 2:

Name: Sample

Phone:555-555-5555

Primary Care Physician:

Name: Dr. CareAboutMe

Clinic: WeTakeAll

Phone: 555-555-5555

Insurance Provider:

Carrier: Medicare

Subscriber / Policy #:90-5489885

Medical Documents:

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