1. Telephone Numbers & Information

Telephone Numbers & Information

Emergency Medical Service (EMS): _______________________________________________________________

Campus Security: ______________________________________________________________________________

Fire: ________________________________________  Police: _________________________________________

Poison Control Center:  800.222.1222

Local Poison Control Center:  ____________________________________________________________________

National Suicide Prevention Lifeline:  800.273.8255

Community Urgent Care Center: ________________________ Campus Urgent Care: _______________________

Student Health Services: ____________________________ After Hours Number: __________________________

Student Counseling/Mental Health Services: ________________________________________________________

Personal Physician: ____________________________________________________________________________

Nearest Hospital: _________________________________________ Pharmacy: ___________________________

Health Insurance Information

Company & Telephone Number: __________________________________________________________________

Address: _____________________________________________________________________________________

Policyholder’s Name & Policy Number: ____________________________________________________________

What to Tell Your Doctor or Provider

(Make copies as needed.)

Use this summary when you call or visit a doctor or provider.

Symptoms

1. oPain (location and severity)
   

2. oNausea/vomiting
   

3. oSkin problems (location and description)
   

4. oEye, ear, nose, throat problems
   

5. oFever/chills
   

6. oBreathing problems
   

7. oStomach problems
   

8. oAnxiety, depression
   

9. oDuration of symptoms
   

10. oConstant or intermittent
    

11. oThings that make symptoms better or worse
    

Other problems:  _______________________________________________________________________________

Specific questions I have now: ____________________________________________________________________

What I need to do:  _____________________________________________________________________________

Medications

Prescribed and over-the-counter medications I take:

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Herbs and supplements I take:

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Medications I’m allergic to:

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________

Name / Dose: _________________________________________________________________________________