Admission Info Finlay Watson DOB 15/06/1967

Health History

Source of Information	Finlay Watson
Reason for Visit
Health History
Height		cm	Weight		lbs
Allergies	Reaction type:	Penicillin		Severity:	rash
Language Spoken	english		Reading/Writing		english
Family History	CV disease – father – MI at 70 years old
Previous Illnesses
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; 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	OD
	Ticagrelor	90 mg	po	OD

Last Name:	First Name:	Middle Name:	Age:	DOB:	Gender:	Marital Status:	Ethnicity:	Religion:
Watson	Finlay	S.	57	15/06/1965		marrried		unknown
Address:	Street 123 Columbia Street			Apt. #	City	Province	Postal Code	MRP
Address:					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
Address:
Home Phone			Cell Phone
Employer Information
Name
Address	Street			Suite #	City	Province:	Postal Code
Address
Primary Insurance Information
Name of Insurance Company:			Medicare		Phone:
Policy #
Group name:
Group Number:
Insured:	Last:		First:		MI:
	Sex:		Relation:		DOB:
Emergency Contact
Name:	Sally Watson			Relationship:	partner
Address:				City:
Phone:				Province:		Postal: