allergies / flu / Fainting / high blood pressure Chest Pain With activity At rest Chest Pain / HIV Cancer / Arthritis / Blood Clots / congenital abnormality / heart attacks / Neurologic disease Parkinsons Disease Seizures / Hepatitis / illness / Liver disease / infections / Medical Conditions Kidney disease Dialysis Transplant Bladder/Urinary disorder / /
MedicalTreatment
catheter / angioplasty / antibiotics / Blood Transfusion / Self Care / Cardiac catheterization / back surgery / Heart surgery / Surgery / Dialysis / blood transfusions / /
Organization
Intensive Care FOR HOSPITAL / JOHNS HOPKINS HOSPITAL PATIENT HISTORY PREOPERATIVE CENTER / Time Date Validation Signatures/Titles GRAPHICS BY JHMI CENTER / GRAPHICS BY JHMI CENTER FOR INFORMATION SERVICES Date jH2010-4 / GRAPHICS BY JHMI CENTER FOR INFORMATION SERVICES jH2010-3 / GRAPHICS BY JHMI CENTER FOR INFORMATION SERVICES jH2010-1 / /
Person
Surgery / / /
Position
Clothing Money/Jewelry Dentures/Partials Glasses/Contacts Heating Aide / Surgeon / Wheelchair Oxygen Home Health Aide / TDD Visiting Nurse / /
Product
Regular exercise Medical History Heart Disease High Blood Pressure On medication / coumadin / Thyroid medication / medrol / prednisone / Motrin / /
THE JOHNS HOPKINS HOSPITAL PATIENT HISTORY PREOPERATIVE CENTER for addressograph plate