Medical Information

Name: Address: City, State, Zip: Patient Phone: Soc. Sec. No: Employer: Diagnoses Kennedy's Disease (aka, Spinal Bulbar Muscular Atrophy)  Caution: Because of the medical condition, certain anesthetics could be hazardous to the patient’s health and may be life threatening. The main areas of Medical concern are how the anesthetic agents will affect the patient’s muscles Concerns (including the heart) and the ability to breathe afterwards.  Other Concerns: The patient does not tolerate changes in body temperature as well as normal patients and needs to be kept well hydrated.  Physician names, specialty & telephone number, such as James Doe, M.D. Doctors (primary care) 713-555-3333; John Doe, M.D. (neurologist) 713-555-4545  Primary: Insurance  Secondary:  List specific medication & type of reaction, such as: Motrin (hives), Amoxil (GI Allergies upset Medical  Past surgeries along with dates History  Other important illnesses and health issues Routine  Name of each medication, dose & frequency, whether prescription or over the Medications counter (include vitamins if taken regularly) Other  Name of each medication, dose & frequency, whether prescription or over the Medications counter Medical  Durable Power of Attorney (where are copies held - – name, address & phone Directives number)  Living Will (where are copies held – name, address & phone number) Emergency  Primary: (include relationship, home/work/cell phone numbers) Contact  Secondary: (include relationship, home/work/cell phone numbers)  Additional: (include relationship, home/work/cell phone numbers)

4/8/2018 1 Medical Information.Doc

Medical Information - Name (Date)