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Date Portable Health Profile PHP Data Collection Form This form contains information that is confidential. It may contain information that is privileged or exempt from disclosure under applicable law. 1. Personal Information Name Date of Birth Street City Home Phone State Mobile Phone 2. Emergency Contacts Relationship Address Phone 1 3. Health Insurance Information Insured Name ID Number Group Name Subscriber Name Primary Insurance Plan Name Phone Number Group Number Secondary Insurance Plan Name Claim Manager Claim Number Type text Workers Compensation Agency Name Sex Advance Directive Yes No Primary Language 4. Immunizations Flu Vaccine Pneumonia Vaccine Tetanus 5. Risk Factors Legally Blind Hip Precautions Swelling Problems Date Administered Chicken Pox Vaccine HPV Sternal Precautions Prone to fall Bleeding Precaution 6. Physicians Other Healthcare Providers involved in my care Senior Network Health VNA Meals on Wheels Oxygen Provider Home Health Care Primary Physician Dentist Specialist Healthcare Provider 7. Preferred Hospital 8. Allergies Please list any drug food substances to which you have had an allergic or bad reaction* 9. Medications/ Vitamins/Supplements Dosage Frequency ex. Twice a day 10. Medical Devices prosthesis CPAP Bipap pacemaker wheelchair pumps hearing aids durable medical equipment Device Provider Provider Number Date obtained or last service 11. Known Medical Conditions/Diagnoses Anemia Arthritis Asthma Bleeding Tendency Cancer Depression Diabetes Heart Disease Hepatitis High Blood Pressure High Cholesterol Kidney Disease Liver Disease Lung disease SCI Stroke/TIA TBI Ulcers Others 12. Special Needs Functional Mobility Vision/Hearing Swallowing Need another copy Visit website http //www. 1. Personal Information Name Date of Birth Street City Home Phone State Mobile Phone 2. Emergency Contacts Relationship Address Phone 1 3. Health Insurance Information Insured Name ID Number Group Name Subscriber Name Primary Insurance Plan Name Phone Number Group Number Secondary Insurance Plan Name Claim Manager Claim Number Type text Workers Compensation Agency Name Sex Advance Directive Yes No Primary Language 4. Health Insurance Information Insured Name ID Number Group Name Subscriber Name Primary Insurance Plan Name Phone Number Group Number Secondary Insurance Plan Name Claim Manager Claim Number Type text Workers Compensation Agency Name Sex Advance Directive Yes No Primary Language 4. Immunizations Flu Vaccine Pneumonia Vaccine Tetanus 5. Risk Factors Legally Blind Hip Precautions Swelling Problems Date Administered Chicken Pox Vaccine HPV Sternal Precautions Prone to fall Bleeding Precaution 6. Immunizations Flu Vaccine Pneumonia Vaccine Tetanus 5. Risk Factors Legally Blind Hip Precautions Swelling Problems Date Administered Chicken Pox Vaccine HPV Sternal Precautions Prone to fall Bleeding Precaution 6. Physicians Other Healthcare Providers involved in my care Senior Network Health VNA Meals on Wheels Oxygen Provider Home Health Care Primary Physician Dentist Specialist Healthcare Provider 7.

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