Admission Info Finlay Watson DOB 15/06/1965
Health History
| Source of Information | Finlay Watson | |||||||
| Reason for Visit | NSTEMI | |||||||
| Health History | ||||||||
| Height | 188 cm | Weight | 80 kg | |||||
| Allergies | Reaction type: | Penicillin | Severity: | rash | ||||
| Language Spoken | english | Reading/Writing | english | |||||
| Family History | CV disease – father – MI at 70 years old | |||||||
| Previous Illnesses | hypertensioin | |||||||
| ARO Screening | yes | MRSA: | neg | CPO: | neg | Close contact with someone positive: | ||
| Isolation Precautions | Type: | N | ||||||
| Surgical History | Bypass surgery for left femoral artery occlusion 2018; Cardiac angioplasty – 3 stents 2010 | |||||||
| Wounds | N/A | |||||||
| Aggressive Behavior Screening | History of Violence: | N/A | Physically violent: | Verbally Aggressive: | AGG FORM | |||
| Dietary History | regular | Diet Type: | Consistency: | |||||
| Substance Use | Type: | ETOH – occasional | Last Used: | one week ago | ||||
| Substance Use | Type: | Last Used: | ||||||
| Housing | Barriers: | N | Community Support: | N/A | ||||
| Current Medications | Drug | Dose | Route | Freq | Comments | |||
| ASA | 81 mg | po | daily | |||||
| Ticagrelor | 90 mg | po | daily | |||||
Patient Demographics
| Last Name: | First Name: | Middle Name: | Age: | DOB: | Gender: | Marital Status: | Ethnicity: | Religion: |
| Watson | Finlay | S. | 59 | 15/06/1965 | marrried | unknown | ||
| Address: | Street 123 Columbia Street | Apt. # | City | Province | Postal Code | MRP | ||
| Kamloops | BC | V2V 1B1 | Hart | |||||
| Home Phone: | 250-555-5555 | Cell Phone: | ||||||
| Guarantor/Legal Guardian of Minor (If different from patient) | ||||||||
| Last Name: | First Name: | Middle Name: | Age: | DOB: | Sex: | Relation: | ||
| Address: | Street | Apt. # | City | Province: | Postal Code | |||
| Home Phone | Cell Phone | |||||||
| Employer Information | ||||||||
| Name | ||||||||
| Address | Street | Suite # | City | Province: | Postal Code | |||
| Primary Insurance Information | ||||||||
| Name of Insurance Company: | Medicare | Phone: | ||||||
| Policy # | ||||||||
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| Insured: | Last: | First: | MI: | |||||
| Sex: | Relation: | DOB: | ||||||
| Emergency Contact | ||||||||
| Name: | Sally Watson | Relationship: | partner | |||||
| Address: | City: | |||||||
| Phone: | Province: | Postal: | ||||||
