Sisters, Servants of the Immaculate Heart of Mary by xSo9LLp

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									                               Sisters, Servants of the Immaculate Heart of Mary
                                          Personal Information Sheet


Name                                                      Family Name
Date of Birth                                             S.S. #
Driver’s License #                                        Name on License
Date of Profession                                        Feast Day
Blue Cross/Blue Shield Group #                            Medicare # (if applicable)
Years of Teaching Experience                              Last Defensive Driving
Date of Transfer                                          Transferred from
Degree                                                    College/University
Certification




                                               Family Information


      Closest Relative______________________________        Relationship ____________________________
      Address____________________________________           City ___________________________________
      Phone – Home ______________________________           Phone – Work __________________________


      Do you wish this person to be contacted in case of emergency?      ______ yes ______ no




                                          Alternate Family Information


      Name ____________________________________             Relationship ____________________________
      Address___________________________________            City ___________________________________
      Phone – Home _____________________________            Phone – Work __________________________


      Do you wish this person to be contacted in case of emergency?      ______ yes ______ no
                                            Medical History Information Sheet


                                     Attending Physician (In case of emergency)
Name_____________________________________                               Phone_________________________________


                Specialist you are currently seeing: (Cardiologist, Allergist, Surgeon, etc.)
Name_____________________________________                               Type of Specialist_______________________
Address___________________________________                              Phone_________________________________
Name_____________________________________                               Type of Specialist_______________________
Address___________________________________                              Phone_________________________________


                                                     Past Hospitalizations
Date                 Name of Hospital                                   Reason for Hospitalization
___________          _____________________________                      _______________________________________
___________          _____________________________                      _______________________________________
___________          _____________________________                      _______________________________________
___________          _____________________________                      _______________________________________


       Present Medications: Please include eye drops, ointments, laxatives, allergy injections
Name                 Strength                                           How often you use it
___________          _____________________________                      _______________________________________
___________          _____________________________                      _______________________________________
___________          _____________________________                      _______________________________________
___________          _____________________________                      _______________________________________


Allergies            Food__________________________________________________________________
                     Medicine_______________________________________________________________
Please check any of the items that pertain to you:
________ eye glasses                         ________ contact lenses                         _________hearing aid
________ hip replacement                     ________ cane                                   _________walker
________ knee replacement                    ________ dentures                               _________partial plate
________ pace maker
Are you an organ donor? ________ yes ________ no
If yes, what arrangements have you made? _________________________________________________
Have you signed the Community Durable Power of Attorney? ________ yes ________ no
Please list any other specific information concerning your medical condition that has not been included in this form.
                                                                                             Thank you, Sister.

								
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