General Information		Name John P. Doe Date of Birth 1935-05-28 Blood Type O+ Gender N/A Age 75 Uses Tobacco N/A Uses Alcohol N/A

Emergency Contacts		Name Phone Relation Mary M. Doe (480) 123-4567 spouse
*This is the primary contact.

Physician Contacts		Name Phone Specialty Organization P. Jones* (602) 123-4567 Internal Medicine
*This is the primary physician.

Medications		Name Strength, Dose, Usage Date Prescribed By Nexium 40mg, 1 tab x2 daily, 1990-01-01 P. Jones Gluchophage 1000mg, 1 tab daily, diabetes 1990-01-01 P. Jones Lopressor 150mg, 1 tab daily, 1990-01-01 P. Jones Lisinopril 5mg, 1 tab daily, 1990-01-01 P. Jones Toprol XL 100mg, 1 tab daily, 1990-01-01 P. Jones Lasix 40mg, 1 tab daily, 1990-01-01 P. Jones Celebrex 200mg, 1 tab daily, 1990-01-01 P. Jones

Allergies		Name Type Reactions Aspirin drug Hives Penicillin drug rash Sulfur drug nausea Shell Fish food swelling

Conditions		Name Comment Doctor Allergies P. Jones Arthritis P. Jones Asthma P. Jones Diabetes P. Jones

Procedures		Name Date Comment Doctor Triple Bypass 1996-04-20 being monitored by cardiologist P. Jones

Devices		Name Date Comment Doctor Holter Monitor 1996-04-20 monitored by cardiologist P. Jones

Immunizations		Name Date Booster Comments Influenza 1990-01-01 1991-12-02 Hepatitis A 1990-01-01 2005-10-27 Varicella 1990-01-01 2004-10-22 Measles, Mumps & Rubella 1990-01-01 1992-03-20

Insurance Policies		Provider Company Member ID Group ID Medicare 9876-54321-000

Family History		Title Description Cancer Sister, Grandmother.

Member Notes		Title Description test asdf J.Doe Contact XYZ Funeral home for final arrangements and contact Saint Jude...

Member Files EKG's, XRays and Images		Title Description ekg here are my images of my arm