LifeBadge

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 :
  Male
  Female
Blood group : 
Rhesus 
Remarks - insurance : 

Allergies

Aspirin 
Penicillins 
Sulfonamides 
Local anesthetics 
Latex 
Iodine 
Anti-inflammatory compounds 
Insects 
Radiologic substances 
Cortisone or derivates 
Fructose 
Galactose 
Gluten 
Others 

Hereditary diseases

Hemophilia 
Porphyria 
Thalassaemia 
Others 

Medical history

Coagulopathies 
Anaemia 
Myocardial infarction 
Angina pectoris 
Congenital heart deseases 
Deseases of the heart valves 
Arterial hypertension 
Heart arrhythmia 
Heart failure 
Cystic fibrosis 
Pulmonary insufficiency (serious) 
Asthma 
Renal insufficiency 
Nephrolithiasis 
Hepatic insufficiency 
Gastric or duodenal ulcera 
WIPPLE-disease 
Diabetes 
Leukaemia 
Hypothyroidism 
Hyperthyroidism 
Multiple sclerosis 
Poliomyelitis 
Epilepsy 
Cerebral handicap 
Muscle dystrophia 
Myasthenia 
Diseases of the spinal cord 
Buccal tumor or deformation 
Larynx tumour 
Deafness (deaf) 
Blindness (blind) 
One-eyed 
Muteness (dumb) 
Glaucoma (ocular hypertension) 
Prostate, prostatitis 
Malaria 
Viral hepatitis 
AIDS 
Tuberculosis 
Other disease 

Dependencie(s)

Tobacco 
Alcohol 
Coffee 
Other 

Surgical history

Brain surgery 
Brain tumour 
Cerebral aneurysm 
Cerebral injury 
Cerebral haemorrhage 
Coronary bypass 
Cardiac graft 
Heart valve plastic surgery 
Heart valve replacement 
Congenital disease surgery 
Carotid obstruction 
Coronary "Stent" 
Coronary dilatation 
Partial pneumonectomy 
Total pneumonectomy 
Partial gastrectomy 
Total gastrectomy 
Nephrectomy 
Cholecystectomy 
Thoracic aortic aneurysm 
Abdominal aortic aneurysm 
Abdominal aortic bifurcation 
Hysterectomy 
Cystectomy 
Appendicectomy 
Colectomy 
Duodenopancreatectomy 
Bone tumour 
Slipped disc 
Fracture of the spinal column 
Oesophageal tumour 
Cataract 
Heart pacemaker 
Model of pacemaker 
Morphine pump implant 
Nerve stimulator implant 
Brain ventricular drainage 
Arteriovenous fistula 
Splenectomy 
Cesarian section 
Liver transplant 
Kidney transplant 
Heart-lung transplant 
Member amputation
(finger, hand, forearm, arm,
toe, feet, leg, thigh)
 
Other 

Current Drug treatment

Anticoagulants 
Thrombocyte aggregation inhibition 
Antiarrhythmics 
Antihypertensives 
Beta-blocker 
Digitalis 
Nitrate derivates 
Bronchodilatator 
Oxygen (intermittent/permanent) 
Tricyclic antidepressants 
MAO inhibitors (thymeretica) 
Antiepileptics 
Barbiturates 
Cortisone or corticoids 
Thyroid hormones 
Insulin 
Oral antidiabetics 
Anti-ulcera 
Morphine or morphine derivates 
Antiphlogistics 
Immunodepressants 
Antimyasthenics 
Antabus (disulfiram) 
Benzodiazepine derivates 
Theophylline 
Lithium 
Methadone 
Suprareneal hormones 
Hypophyseal hormones 
Actual medications 

Current long term treatment

radiotherapy for cancer 
Cancer chimiotherapy 
Palliativ care 
Renal dialysis 
Other 

Vaccinations in order at folder's date

Tetanus 
Diphteria 
Whooping cough 
Poliomyelitis 
Varicella 
Measles 
Rubella 
Mumps 
Hepatitis A 
Hepatitis B 
Pneumococcus 
Meningococcus 
Hemophilus Influenzae 
Yellow fever 
Cholera 
Typho´d fever 
Rabies 
Others 

Prosthesis

Contact lenses 
Artificial eye 
Hearing aid 
Dentures 
Glasses 
Platform shoes 
Other prothesis 

Blood / Organs

I accept a possible transfusion of blood or derivatives 
I agree to be organ donor after death 

Others

Profession 
Peculiarities - Other analysis
Specific examinations - Last wills
Indicate Date - Procedure - Results and //