Dear Conference Attendee,
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- Georgia Payne
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3 Dear Conference Attendee, When it comes to navigating the healthcare system and working with various medical professionals, keeping one s medical information well-organized and easily accessible can often be a challenging task. With the generous support of Actelion Pharmaceuticals Canada Inc., the Scleroderma Society of Canada and Sclérodermie Québec created the Healthcare Management Binder to assist individuals in successfully organizing, tracking, and cataloging their medical information. Please note, however, that the Healthcare Management Binder and all materials enclosed are not a substitute for professional medical advice. The binder should be used as a resource in conjunction with one s healthcare provider(s). We hope this binder serves as an easy, efficient tool in managing your overall healthcare experience. Sincerely, Sclérodermie Québec Scleroderma Society of Canada Sclérodermie Québec 550, chemin Chambly, Suite 040, Longueuil (Quebec) J4H 3L8 ( sclerodermiequebec@videotron.ca
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5 Personal Information NAME: GENDER : Male Female ADDRESS: Health Insurance # : ProvincE : Date OF BIRTH : PLACE OF BIRTH : YR-MM-DAY TELEPHONE (home) : TELEPHONE (WORK) : telephone (CELL) : ORGAN DONOR : YES NO PRIMARY CARE PHYSICIAN : TELEPHONE : BLOOD TYPE : Emergency Contact Name : TELEPHONE : RELATIONSHIP : MEDICAL CONDITION : Emergency Contact Address: TELEPHONE N o 2 : Emergency Contact Name : DRUG ALLERGIES : TELEPHONE : RELATIONSHIP : Emergency Contact Address: Food or Environmental Allergies: TELEPHONE N o 2 :
6 Employment Information EMPLOYER : STUDENT : YES NO EMPLOYER S PHONE : ADDRESS : JOB DESCRIPTION : Primary Insurance Company : Insurance Information ADDRESS: POLICY #: TELEPHONE : GROUP # : Name of Policy Holder : RELATIONSHIP : Secondary Insurance Company : ADDRESS: POLICY #: TELEPHONE : GROUP # : Name of Policy Holder : RELATIONSHIP : Drug Insurance # : Hospital ID Card # : COMMENTS :
7 Current Medications Pharmacy #1 : PHONE # : Pharmacy #2 : PHONE # : MEDICATION RECORD Medication s Name & Strength DOSAGE TIME(S) # Times/Day Date Started Reason for Taking COMMENTS :
8 Current Medications (Cont.) Pharmacy #1 : PHONE # : Pharmacy #2 : PHONE # : MEDICATION RECORD Medication s Name & Strength DOSAGE TIME(S) # Times/Day Date Started Reason for Taking COMMENTS :
9 Cardiopulmonary Records Echocardiogram DATE LOCATION FINDINGS RECORD OBTAINED Pulmonary Function Tests (PFT) DATE LOCATION FINDINGS
10 Cardiopulmonary Records (Cont.) Blood Pressure Record DATE time Position (e.g. sitting) Arm R or L location reading pulse
11 Gl Symptom Tracker Symptom DATE time TREATMENT COMMENTS COMMENTS :
12 Weight Record DATE Weight Time of Day Special Diet / Comments COMMENTS :
13 Dental Exam Record Name of Dentist : ADDRESS : PHONE # : comments : PRIMARY DENTAL INSURANCE ADDRESS : PHONE # : Policy #: GROUP # : Name of Policy Holder : Relationship : DRY MOUTH DATE Name of Dentist DRY MOUTH FINDINGS Complications / Comments/ Treatment
14 Dental Exam Record DATE NAME OF DENTIST CLEANING EXAM FLUORIDE X-RAY FOLLOW- UP COMMENTS COMMENTS :
15 Diagnostic Tests / Blood Work DATE LOCATION TYPE OF TEST REASON RECORDS RECEIVED YES NO COMMENTS :
16 Diagnostic Tests / Blood Work (Cont.) DATE LOCATION TYPE OF TEST REASON RECORDS RECEIVED YES NO COMMENTS :
17 History of Hospitalizations and Surgeries HOSPITAL DATE ADMITTED DATE OF SURGERY DATE DISCHARGED PHONE # : Inpatient/Outpatient Reason for Hospitalization/ Type of Surgery: ADDRESS : Physician s/surgeon s Name : COMPLICATIONS : HOSPITAL DATE ADMITTED DATE OF SURGERY DATE DISCHARGED PHONE # : Inpatient/Outpatient Reason for Hospitalization/ Type of Surgery: ADDRESS : PHYSICIAN S/SURGEON S NAME : COMPLICATIONS : COMMENTS :
18 History of Hospitalizations and Surgeries (Cont.) HOSPITAL DATE ADMITTED DATE OF SURGERY DATE DISCHARGED PHONE # : Inpatient/Outpatient Reason for Hospitalization/ Type of Surgery: ADDRESS : Physician s/surgeon s Name : COMPLICATIONS : HOSPITAL DATE ADMITTED DATE OF SURGERY DATE DISCHARGED PHONE # : Inpatient/Outpatient Reason for Hospitalization/ Type of Surgery: ADDRESS : PHYSICIAN S/SURGEON S NAME : COMPLICATIONS : COMMENTS :
19 Optometry / Ophthalmology Treatment Record DATE Physician s Name REASON FOR VISIT COMMENTS 19
20 Optometry / Ophthalmology Treatment Record (Cont.) DATE Physician s Name REASON FOR VISIT COMMENTS
21 Specialist Visits Scleroderma patients experience a broad spectrum of symptom manifestations. These medical issues cause there to be a need to visit a number of healthcare professionals. Please use this page to record visit to specialists sush as: Rheumatologists, Pneumologists, Cardiologists, Gastroenterologists, Dermatologists, Nephrologists, Vascular Surgeons, etc. DATE Name/Type of specialist Reason for Visit Diagnosis Recommended Treatment COMMENTS :
22 Specialist Visits (Cont.) DATE Name/Type of specialist Reason for Visit Diagnosis Recommended Treatment COMMENTS :
23 Raynaud s Phenomenon (Discoloration and sensation of numbness of the fingers or toes triggered by cold or stress) Symptoms Severity Scale 1 (Slight) to 10 (Severe) Frequency: Date, Time, Duration Protective Measures against Cold and Stress Medication or Treatment Capillaroscopy/ Date Comments: Digital Ulcers (DU) (Open and painful sores on the finger/toe tips requiring time to heal) Symptoms Date Protective Measures Medication or treatment Comments:
24 Specialists List NAME ADDRESS TELEPHONE
25 Legal Documents (Originals) Living Will A document where the patient can describe any lifesustaining treatment he/she may want prior to the patient being unable to make these decisions. Health Care Power of Attorney This is a legal document where the patient gives another person the power to make decisions about the patient s medical care if the patient is no longer able to communicate. Do Not Resuscitate form Intended to help people in the final stages of terminal illness or who suffer from a serious condition. It informs healthcare professionals to forgo resuscitation attempts such as, CPR, intubation, defibrillation, administration of certain drug, etc. DNR (Do Not Resuscitate) Directive A form in which a patient stipulates that no extraordinary measures are to be used. DNR Order - A physician s order on the chart stating that extraordinary measures are not to be used in an attempt to save a patient s life. Birth Certificate Release(s) for Medical Information It is strongly recommended to consult a lawyer or a notary to learn more about required documents or other documents that may be relevant based on your personal situation. Disclaimer Because the manifestations and severity of scleroderma vary among individuals, personalized medical management is essential. The Scleroderma Society of Canada and Sclérodermie Québec have created the medical management binder as a tool and strongly recommends all treatments be discussed with the patients physician(s) for proper evaluation and treatment recommendations.
26 Sclérodermie Québec 550, chemin Chambly, Suite 040, Longueuil (Québec) J4H 3L8 ( sclerodermiequebec@videotron.ca Our mission SUPPORT Help people with scleroderma by providing moral and medical support. Research Raise funds for scleroderma research. Stimulate and support financially research aimed at defeating scleroderma. Information Develop information tools for the public and stakeholders in the medical community.
27 Donation Form The 100,000 Friends Challenge to Defeat Scleroderma YES! I WANT TO HELP ADVANCE RESEARCH AND SUPPORT SCLERODERMA PATIENTS SELECT AN AMOUNT : $10 $25 $100 $200 OTHER DONATION AMOUNT : FULL NAME : AN INCOME TAX RECEIPT WILL BE ISSUED (FOR ALL DONATIONS OF $25 OR MORE) AND DELIVER TO THE FOLLOWING ADDRESS : ADDRESS : CITY : Province : POSTAL CODE : TELEPHONE : ADDRESS : METHOD OF PAYMENT q ChECK (Payable to Sclérodermie Québec) q credit card q Visa q MasterCard card number : expiration date (MM/YY) : q I WOULD LIKE MY NAME TO APPEAR ON THE 100,000 FRIENDS CHALLENGE S LIST q I WISH TO RECEIVE SCLÉRODERMIE QUÉBEC S NEWSLETTER q BY MAIL q BY Signature : Date : Please return this completed form with your donation to : SCLÉRODERMIE QUÉBEC, 550 chemin de Chambly, Suite 040, Longueuil (Québec) J4H 3L8 TO MAKE A DONATION ONLINE : Charities registration Number RR0001
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