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PAHINA NG MGA IMPORMASYON SA PANAHON NG · PDF filepahina ng mga impormasyon sa panahon ng emerhensya tawagan ang 911

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  • Pangalan ________________________________________________ Apelyido __________________________________________________ (First Name) (Last Name)

    Tirahan _________________________________________________________________________ Numero ng Apartment ______________ (Address) (Apartment Number)

    Lungsod _____________________________________________________________________ Postal Code (City) (Postal Code)

    PangunahingTelepono ( ) - PanghalilingTelepono ( ) - (Main Phone) (Alt. Phone)

    Kard Pangkalusugan - - - Petsa ng Kapanganakan / / (Health Card) (Birth Date)

    (Mga) PangunahingWika __________________________________________________________________ Kasarian L B(Primary Language) (Gender) (M) (F)

    Paunang Tagubilin sa Pangangalaga Naka-file sa ________________________________________________________ (Advanced Care Directive) (On file with)

    PA H I N A N G M G A I M P O R M A S Y O NS A PA N A H O N N G E M E R H E N S YA

    TAWAG A N A N G 911

    Sakit sa Puso (angina, atake sa puso)(Cardiac (angina, heart attack, bypass, pacemaker))

    Dyabetiko (IDDM/NIDDM)(Diabetic (insulin / non insulin dependant))

    Kanser(Cancer)

    Stroke o Atake sa Utak/TIA(Stroke/TIA)

    COPD (emphysema o sakit sa baga, brongkitis)(COPD (emphysema, bronchitis))

    Alzheimer(Alzheimer)

    Alta-presyon(Hypertension (high blood pressure))

    Sumpong (convulsions)(Seizure (convulsions))

    Demensya(Dementia)

    Paninikip ng Mahinang Puso(Congestive heart failure)

    Hika (Asthma)

    Saykayatriko(Psychiatric)

    Iba pa __________________________________________________________________________________________________________________ (Other)Iba pa __________________________________________________________________________________________________________________ (Other)Iba pa __________________________________________________________________________________________________________________ (Other)

    KAUGNAY NA KASAYSAYANG PANG-MEDIKAL RELEVANT MEDICAL HISTORY

    I M P O R M A S Y O N N G M A L A L A P I T A N CONTACT INFORMATION

    araw buwan taon

    Malalapitan sa Emerhersya 1 _________________________________________________________________________________________ (Emergency Contact 1)

    PangunahingTelepono ( ) - PanghalilingTelepono ( ) - (Main Phone) (Alt. Phone)

    Malalapitan sa Emerhersya 2 _________________________________________________________________________________________ (Emergency Contact 2)

    PangunahingTelepono ( ) - PanghalilingTelepono ( ) - (Main Phone) (Alt. Phone)

    PangunahingTagapangalaga ng Kalusugan __________________________________________________________________________ (Primary Care Provider)

    Telepono ( ) - (Phone)

    www.torontoparamedicservices.ca

    Tagalog

    (day) (month) (year)

  • N A T A T A N G I N G M G A K O N S I D E R A S Y O N SPECIAL CONSIDERATIONS

    Nakakahawang Impeksiyon / Sakit _________________________________________________________________________________ (Communicable Infection / Disease)

    Iba pa ________________________________________________________________________________________________________________ (Other)

    Kaanib na Ospital ____________________________________________________________ Ekstensibong Kasaysayan y(Hospital affiliation) (Extensive history)

    Espesyalidad (Dialysis, neuro, etc.) __________________________________________________________________________________ (Specialty (dialysis, neuro, etc.))

    Kinumpleto ni _____________________________________________________________ Petsa / / (Completed by) (Date) araw buwan taon

    M G A M E D I K A S Y O N MEDICATIONS

    P A G G A L A W / P A N D A M A MOBILITY / SENSORY Mga pustiso

    (Dentures) Paningin (kapansanan/mga salamin sa mata)

    (Visual (impairment / glasses / blind)) Pandinig (kapansanan/pantulong sa pandinig)

    (Hearing (impairment / aid / deaf))

    Mobility issues (cane / wheelchair / walker / motorized scooter / prosthetic limb)(Mobility issues (cane / wheelchair / walker / motorized scooter / prosthetic limb))

    Mobility issues (cane / wheelchair / walker / motorized scooter / prosthetic limb)(Mobility issues (cane / wheelchair / walker / motorized scooter / prosthetic limb))

    Mobility issues (cane / wheelchair / walker / motorized scooter / prosthetic limb)(Mobility issues (cane / wheelchair / walker / motorized scooter / prosthetic limb))

    MGA PAKIKIPAG-UGNAYAN PARA SA ALAGANG HAYOP PET CARE CONTACTS

    Pakikipag-ugnayan 1 _______________________________________________ Telepono ( ) - (Contact 1) (Phone)

    Pakikipag-ugnayan 2 __________________________________________ Telepono ( ) - (Contact 2) (Phone)

    Listahan ng mga alagang hayop at mga tagubilin sa pangangalaga ng alagang hayop ____________________________ (List of pets and pet care instructions)

    _______________________________________________________________________________________________________________________

    www.torontoparamedicservices.ca

    M E D I C A L A L L E R G I E S Hindi Kilalang mga Alerhiya Penisilin ASA (Aspirin) Sulpha Codeine(No Known Allergies) (Penicillin) (ASA) (Sulpha) (Codeine)

    Iba pa ________________________________________________________________________________________________________________ (Other)

    M G A A L E R H I Y A S A M E D I K A L MEDICAL ALLERGIES

    1)_____________________________________ 6)____________________________________ 11) ____________________________________

    2)_____________________________________ 7)____________________________________ 12)_____________________________________

    3)_____________________________________ 8)____________________________________ 13)_____________________________________

    4)_____________________________________ 9)____________________________________ 14)_____________________________________

    5)_____________________________________ 10)____________________________________ 15)_____________________________________

    (day) (month) (year)

    Medication 01: Medication 02: Medication 03: Medication 04: Medication 05: Medication 06: Medication 07: Medication 08: Medication 09: Medication 10: Medication 11: Medication 12: Medication 13: Medication 14: Medication 15: No Allergies: Penicillin: ASA: Sulpha: Codeine: Other Allergies: Communicable: Other Consideration: Hosp: Affiliation: Specialty:

    Ext: history:

    Specialty: Dentures: Visual: Visual Conditions: Hearing: Hearing Conditions: Mobility: Mobility Conditions: Pet Contact 1: Pet Phone 1: Pet Contact 2: Pet Phone 2: Pet care 1: Pet care 2: FirstName: Surname: StreetAddress: Apartment: City: PC1: HomeAreaCode: CellAreaCode: HC1: DOB: PrimaryLanguages: gender: AdvCareDirective: ACDOnFile: EmergContact1: EC1AC: EC1CAC: EmergContact2: EC2AC: EC2CAC: PrimaryCareProvider: PCPAC: Cardiac: Stroke: Hypertension: Congestive Heart Failure: CardiacConditions: Diabetic: COPD: Seizure: DiabetesType: Asthma: Cancer: CancerTypes: Alzheimer: Dementia: Psychiatric: PsychiatricConditions: Other Medical History: