SCHEDA INFORMATIVA

IN CASO DI EMERGENZA
CHIAMARE IL 911
INFORMAZIONI DI CONTATTO
Nome

__________________________________________________

Cognome

(First Name)

Italian

CONTACT INFORMATION

___________________________________________________

(Last Name)

Indirizzo ________________________________________________________________________ Numero di appartamento____________

(Address)

(Apartment Number)

Citt ______________________________________________________________________ Codice postale

(City)

(Postal Code)

Telefono principale (

(Main Phone)

Tessera sanitaria

Telefono alternativo (

(Alt. Phone)

Data di nascita

(Health Card)

(Birth Date)

/
giorno
(day)

/
mese

(month)

anno

(year)

Lingua/e principale/i ______________________________________________________________________________ Sesso M

(Primary Language)

(Gender)

Testamento di vita

(M)

F
(F)

In archivio presso _____________________________________________________

(Advanced Care Directive)

(On file with)

Contatto di emergenza 1
(Emergency Contact 1)

______________________________________________________________________________________________

Telefono principale (

Telefono alternativo (

(Main Phone)

(Alt. Phone)

Contatto di emergenza 2

______________________________________________________________________________________________

(Emergency Contact 2)

Telefono principale (

Telefono alternativo (

(Main Phone)

(Alt. Phone)

Operatore sanitario di base ___________________________________________________________________________________________

(Primary Care Provider)

Telefono (

(Phone)

ANAMNESI RILEVANTE
Problemi cardiaci (angina, attacco cardiaco)

RELEVANT MEDICAL HISTORY

Diabete IDDM/NIDDM

Cancro

Ictus/TIA

BPCO (enfisema, bronchite)

Alzheimer

Ipertensione (alta pressione sanguigna)

Crisi epilettica (convulsioni)

Demenza

(Cardiac (angina, heart attack, bypass, pacemaker))

(Stroke/TIA)

(Hypertension (high blood pressure))

Insufficienza cardiaca congestizia

(Congestive heart failure)

Altro

(Diabetic (insulin / non insulin dependant))

(COPD (emphysema, bronchitis))

(Seizure (convulsions))

Asma
(Asthma)

(Cancer)

(Alzheimer)

(Dementia)

Problemi psichiatrici
(Psychiatric)

___________________________________________________________________________________________________________________

(Other)

www.torontoparamedicservices.ca

MEDICINE

MEDICATIONS

1) _____________________________________ 6) ____________________________________ 11) _____________________________________

2) _____________________________________ 7) ____________________________________ 12) _____________________________________
3) _____________________________________ 8) ____________________________________ 13) _____________________________________
4) _____________________________________ 9) ____________________________________ 14) _____________________________________
5) _____________________________________ 10) ____________________________________ 15) _____________________________________

ALLERGIE A MEDICINALI
Nessuna allergia nota

Penicillina
L
Aspirina
M
EDICAL A
L E R G IE Sulfamidici
S

(No Known Allergies)

Altro

MEDICAL ALLERGIES

(Penicillin)

(ASA)

Codeina

(Sulpha)

(Codeine)

_________________________________________________________________________________________________________________

(Other)

CONSIDERAZIONI PARTICOLARI
Infezione contagiosa / Malattia

SPECIAL CONSIDERATIONS

_____________________________________________________________________________________

(Communicable Infection / Disease)

Altro
(Other)

_________________________________________________________________________________________________________________

Affiliazione Ospedale

Anamnesi estesa

_________________________________________________________________

(Hospital affiliation)

(Extensive history)

Cure specialistiche (Dialisi, neuro, ecc.)

____________________________________________________________________________

(Specialty (dialysis, neuro, etc.))

DEFICIT MOTORIO / SENSORIALE

Dentiera
(Dentures)

Problemi di vista (disabilit / occhiali)

MOBILITY / SENSORY

Problemi di udito (disabilit / protesi)

(Visual (impairment / glasses / blind))

(Hearing (impairment / aid / deaf))

Problemi motori (bastone / sedia a rotelle / deambulatore / scooter motorizzato / arto protesico)
(Mobility issues (cane / wheelchair / walker / motorized scooter / prosthetic limb))

CONTATTI PER LA CURA DEGLI ANIMALI DOMESTICI

PET CARE CONTACTS

Contatto 1 ____________________________________________________________ Telefono (

Contatto 2 ____________________________________________________________ Telefono (

(Contact 1)

(Phone)

(Contact 2)

(Phone)

Elenco degli animali domestici e istruzioni per la cura degli animali domestici

__________________________________

(List of pets and pet care instructions)

_______________________________________________________________________________________________________________________

Compilata da ____________________________________________________ Data

(Completed by)

(Date)

giorno
(day)

www.torontoparamedicservices.ca

mese

(month)

anno

(year)