By Sheila Kun RN, BA, BSN, MS

It is time to update your health care plan. Hence, I post and review every January the health care plan form for your update. If you wish to have the Word Version, please feel free to contact us: kunlouis@gmail.com

Health Care Plan  (2024 Update)

Name:                                                              DOB: 

Home address and telephone: 

Emergency contact person: 

Family contact person: 

Address and telephone/contact information: 

Heath Insurance: 

Commercial insurance

Medi-Cal/Medi-Care

Dental Insurance

Others:

In case of emergency (ICE) contact:

Advance directives

Emergency Contact: (Family or the community you are living with)

Date: (updated annually) or more frequently if intermittent illness occurs. 

Primary Attending physician/telephone (and for what medical problem)  : 

Diagnoses: 

1.

2.

3

4.

5.

Current medication                How much to take Indication/reason

1.

2.

3.

4. 

5. 

Pharmacy: (name and address)

Telephone:   

Weight/height

Allergies (to medication/food/others):

OTC meds (over the counter):

Primary doctor: 

Contact information:

Medical Specialist:                       What medical problem             Medication

Diet/Nutrition:

Equipment/supplies Company                     Phone/contact

Activities of daily living: (walking, wheel chair, independent in preparing meal, out-shopping, activities outside the house without supervision?)

Glasses: 

Dentures: 

Incontinent/continent:

Fall risk?                     

Adaptive devices:  

Driving: 

Mental status:

Past surgeries: 

Past emergency room visits (last 2 years):  

Pertinent Past Health History:

          Eyes

           Ears

          Nose/Sinuses

          Mouth/Throat

Neck

Heart

Stomach-Intestines/Endocrine

Kidney/Bladder  

Muscle/Skeletal  

Other Diseases

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1. Family History:  

Alcohol    Asthma   Bleeding disorder   Cancer   Depression  Diabetes Glaucoma  Heart disease  Lung Disease  Kidney Disease  Seizures Thyroid Disease  

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