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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 : |
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| 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 | |
| Typhoïd 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 | |
Specific examinations - Last wills Indicate Date - Procedure - Results and // | |