Emergency Room Visit Check List - KLTV.com - Tyler, Longview, Jacksonville |ETX News

9/25/04-Smith County

Emergency Room Visit Check List

 

                                       Emergency Room Visit Checklist:

 

Name:___________________________ Telephone Number:____________________

Address:______________________________________________________________

 

Medications:

Name:_________________________ Dosage:________ Times Taken Daily:__________

Name:_________________________ Dosage:________ Times Taken Daily:__________

Name:_________________________ Dosage:________ Times Taken Daily:__________

Name:_________________________ Dosage:________ Times Taken Daily:__________

Name:_________________________ Dosage:________ Times Taken Daily:__________

Name:_________________________ Dosage:________ Times Taken Daily:__________

Name:_________________________ Dosage:________ Times Taken Daily:__________

Name:_________________________ Dosage:________ Times Taken Daily:__________

 

Are you allergic to any medications? If yes, list and name reaction.

______________________________________________________________________
______________________________________________________________________­­­

Medical Conditions:

______________________________________________________________________
______________________________________________________________________­­­

Allergies:

______________________________________________________________________
______________________________________________________________________­­­

 

Physician(s):

Name:________________________________ Telephone Number:__________________

Name:________________________________ Telephone Number:__________________

Name:________________________________ Telephone Number:__________________

Name:________________________________ Telephone Number:__________________

 

 

Family Medical History: (Does anyone in your family have or have had a medical condition?)

Relation to Patient:____________________ Medical Condition:____________________

Relation to Patient:____________________ Medical Condition:____________________

Relation to Patient:____________________ Medical Condition:____________________

Relation to Patient:____________________ Medical Condition:____________________

Relation to Patient:____________________ Medical Condition:____________________

Relation to Patient:____________________ Medical Condition:____________________

Relation to Patient:____________________ Medical Condition:____________________

Relation to Patient:____________________ Medical Condition:____________________

  • NewsMore>>

  • Sports WebXtra: UT-Tyler hosts special Olympics

    Sports WebXtra: UT-Tyler hosts special Olympics

    Tuesday, March 28 2017 12:13 AM EDT2017-03-28 04:13:30 GMT
    UT-Tyler athletics hosting special olympics on Monday night.UT-Tyler athletics hosting special olympics on Monday night.

    The UT-Tyler Student Athlete Advisory Committee hosted its second annual special Olympics with swoop on Monday night. Numerous Patriot athletes took time out of their normal practice and school routine to participate in the event and give kids a night of fun they normally don't experience.

    More >>

    The UT-Tyler Student Athlete Advisory Committee hosted its second annual special Olympics with swoop on Monday night. Numerous Patriot athletes took time out of their normal practice and school routine to participate in the event and give kids a night of fun they normally don't experience.

    More >>
  • Chapel Hill officially hires Jason Hooker

    Chapel Hill officially hires Jason Hooker

    Tuesday, March 28 2017 12:08 AM EDT2017-03-28 04:08:51 GMT
    Jason Hook officially hired at Chapel Hill.Jason Hook officially hired at Chapel Hill.

    A new era of Chapel Hill football will begin this fall. Jason Hooker's hiring became official at Monday night's CHISD board meeting. Hooker, who comes over from Brownsboro, is replacing Thomas Sitton as head coach and athletic director.

    More >>

    A new era of Chapel Hill football will begin this fall. Jason Hooker's hiring became official at Monday night's CHISD board meeting. Hooker, who comes over from Brownsboro, is replacing Thomas Sitton as head coach and athletic director.

    More >>
  • Sports WebXtra: Blake Lynch impressing during Baylor spring practices

    Sports WebXtra: Blake Lynch impressing during Baylor spring practices

    Tuesday, March 28 2017 12:02 AM EDT2017-03-28 04:02:09 GMT
    Matt Rhule is excited about Lynch's progress.Matt Rhule is excited about Lynch's progress.

    Former Baylor standouts Mount Pleasant product KD Cannon and Linden-Kildare native Shock Linwood will get their chance on April 5th to workout in front of NFL scouts and personnel during the Bears Pro Day. In the meantime, new head coach Matt Rhule is trying to lay the foundation of a program that can compete for a Big 12 title in 2017

    More >>

    Former Baylor standouts Mount Pleasant product KD Cannon and Linden-Kildare native Shock Linwood will get their chance on April 5th to workout in front of NFL scouts and personnel during the Bears Pro Day. In the meantime, new head coach Matt Rhule is trying to lay the foundation of a program that can compete for a Big 12 title in 2017

    More >>
Powered by Frankly