Emergency Medical Service (EMS): _________________________________________________________
Fire: _____________________________________ Police: ______________________________________
Poison Control Center: _______________________ Suicide Prevention Center: _______________________
Health Care Providers:
| Name | Specialty | Telephone Number |
Hospital: __________________________________ Pharmacy: ___________________________________
Employee Assistance Program (EAP): ________________________________________________________
Health Insurance Information:
Company: ________________________________ Phone Number: ________________________________
Address: ______________________________________________________________________________
Policyholder's Name: ________________________ Policy Number: ________________________________
What to Tell Your Health Care Provider
Use this summary when you call or visit a provider. See Talking With Your Doctor/Provider Checklist and Key Questions Checklist for more information.
Symptoms:
Pain
Nausea/vomiting
Fever/chills
Breathing problems
Skin problems
Eye, ear, nose,
throat problems
Stomach problems
Muscle or joint
problems
Other problems: _______________________________________________________________________
Specific questions I have now: ____________________________________________________________
What I need to do: _____________________________________________________________________
Medications:
| Name/Dose | Name/Dose | |
| Medications I take now: | ||
| Medications I'm allergic to: |
HEALTH AT HOME - Your Complete Guide to Symptoms, Solutions, and Self-Care © 1999 by Don R. Powell. American Institute for Preventive Medicine.
Date updated 02/01/99