Member Emergency Profile

Personal Information

Date of Birth:

07/08/1994

(dd/mm/yyyy)

Health Card Number: 

7368086315ER

Full Name: 

Miss
Laura
Peart

Phone: 

+15198729559

Home Address: 

{“street_address”:”109 McNay Street”,”street_address2″:””,”city_name”:”London”,”zip”:”N5Y1L1″,”country_select”:”CA”,”state”:”ON”}

Blood Type: 

-1

Blood Pressure: 

High

Health Insurance: 

Yes

Travel Insurance: 

Yes

Emergency Contact Details

Primary Contact

Name: 

Kianna
Stickle

Phone: 

+15194957413

Secondary Contact

Name: 

Molly
Peart

Phone: 

+15198028036

Family Doctor or Clinic Contact

Type: 

Doctor

Name: 

Dr. C. Koyenikan

Phone: 

+15194555060

Medical Conditions

Medical Conditions

ADHD, Anxiety, Asthma, Eczema, Endometriosis, High-Blood-Pressure, Polycystic Ovary Syndrome, PTSD, Stress

Other Medical Conditions

T2 Flair hyperintensity at the external capsule of the left frontal lobe; C5-C6 left foraminal disc protrusion measuring 3mm with severe left neuroforaminal stenosis with impingement on the left C6 nerve root; T3-T4 posterocentral disc protrusion measuring 3mm indenting the ventral aspect of the thoracic spinal cord, T4-T5 posterocentral disc protrusion measuring 3mm indenting the ventral aspect of the thoracic spinal cord.

Medication Information

Medication List

Anti-Anxiety, Birth-Control, Inhalers

Current Medication Details

Bilastine (Blexten) – 40mg/day Xolair (Injection therapy) – 300mg (150/arm) every 4 weeks Dienogest – 2mg/day Methylphenid HCL ER – 54mg/day Escitalopram Oxalate – 15mg/day Vitamin B12 – 2400mcg/day Alvesco – 800mcg/day Fluticasone Furo – 27.5mcg (as needed) Gabepentin – 300mg/day

Known Medication Allergies

Medication Allergies

Anti-Anxiety, Birth-Control, Inhalers

Other Medication Allergies

Sulfates/Sulfides

Other Allergies

Allergies

Latex, Seasonal Allergies

Other Allergy Details

Pineapple

General Medical Information

Miscellaneous

Do you smoke: 

No

Do you vape: 

No

Do you wear glasses: 

Yes Full Time

Do you wear contacts: 

No

Do you have cataracts: 

No

Are you pregnant: 

No

Other Medical Details

Will not accept blood transfusions under any circumstances. Please see emergency contacts for transfusion alternative preferences. I carry a medical directive regarding my blood fraction and transfusion preferences.

Vaccination Information

Common Vaccinations Details

Hepatitis A/B: 

Yes
01/01/1970

Influenza: 

No

Pneumonia: 

No

Shingles: 

No

Tetanus: 

Yes
01/01/1970

Other Vaccination Details

COVID Information

COVID Vaccination

Have you had COVID:

Yes
01/01/1970

Have you been vaccinated: 

Yes
01/01/1970
Pfizer

Covid Vaccination Reactions or other Details

Fever, nausea, vomiting, flu like symptoms

COVID Booster

Have you had a COVID Booster:

Yes

Booster Type and Date: 

Moderna
01/01/1970

Existing Medical Conditions Preventing Vaccination

No