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:____________________

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