Emergency Medical Information Sheet

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Personal Information:

• Full Name: John Doe

• Date of Birth: January 1, 2000

• Address: 123 Main Street, Springfield, USA

• Phone Number: +1-555-123-4567

• Emergency Contact Name: Jane Doe

  • Relationship: Spouse

  • Phone Number: +1-555-765-4321

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Medical Conditions:

• Primary Conditions (e.g., diabetes, epilepsy): Type 1 Diabetes

• Secondary Conditions: Hypertension

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Allergies:

• Drug Allergies: Penicillin

• Food Allergies: Peanuts

• Other Allergies (e.g., latex): Latex

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Medications:

• Name and Dosage: Insulin (10 units)

• Frequency: Twice daily

• Purpose: Blood sugar regulation

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Medical Devices:

• Type (e.g., pacemaker, insulin pump): Insulin Pump

• Manufacturer and Model: Medtronic MiniMed 770G

• Contact Information for Support: +1-800-646-4633

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Physician Information:

• Primary Physician Name: Dr. Emily Carter

• Specialty: Endocrinologist

• Phone Number: +1-555-987-6543

• Address: 456 Health Ave, Springfield, USA

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Insurance Information:

• Provider: HealthFirst Insurance

• Policy Number: HF-123456789

• Group Number: G12345

• Phone Number for Verification: +1-555-321-6789

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Additional Notes:

• Any specific instructions or notes for emergency responders: The patient requires insulin administration every 6 hours. Carrying glucose tablets.

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