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LifeBadge - 28/12/2025 | |
The information in this health record is the sole and exclusive responsibility of the person who owns it (the holder or his or her legal guardian or agent). This person considers that this information is "public data" voluntarily placed on the LIFEBADGE (the patient or the patient's legal guardian). The user is responsible for all use of this information digital platform and can be used by anyone assisting him if necessary. Any use by a third person will be under the responsibility of this third party who is responsible for verifying the relevance of information if necessary.
General info
| Date record started : | |||
| Date records last updated : | |||
| These questions were answered with the assistance of a doctor (ideal !) : | |||
| Tel/Mobile 1st pers. to contact : | |||
| Tel/Mobile 2nd pers. to contact : | |||
| Tel/Mobile 3d pers. to contact : | |||
| Tel/Mobile 4th pers. to contact : | |||
| Tel of family doctor/specialist : | |||
| Fax of the family doctor / specialist : | |||
| Year of birth : (year only) | |||
| First letter of NAME: (not mandatory) | |||
| First letter of first name : (not mandatory) | |||
| Sex : |
|
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| Blood group : | |||
| Rhesus | |||
| Remarks - insurance : |
Allergies
| Others |
Hereditary diseases
| Others |
Medical history
| Other disease |
Dependencie(s)
| Other |
Surgical history
| Other |
Current Drug treatment
| Actual medications |
Current long term treatment
| Other |
Vaccinations in order at folder's date
| Others |
Prosthesis
| Other prothesis |
Blood / Organs
| Yes | No | To be confirmed (*) | |
| I accept a possible transfusion of blood or derivatives | |||
| I agree to be organ donor after death | |||
| I have read and well understood the 2 questions here before (check the box to confirm) | |||
| (*) = if the box "To be confirmed" is checked, the owner of the LIFEBADGE file has not clearly made a choice yet | |||
Others
| Profession | |
Specific examinations - Last wills Indicate Date - Procedure - Results and // | |
Medications
| CURRENT TREATMENT | ||
| Date | Description | Dosage |
Rare diseases
| Rare disease : | |
| or Synonym : | |
| Details : | |