Asian Caregiving and Technology Education Centers, Inc

`Form 007

FACE SHEET
PERSONAL INFORMATION
TAN, ADELA B.
Client Name: ______________________________
28 Catalina St. Fabian Avenue cor. Catalina St. Azicate Homes, Gen. T. De Leon Valenzuela City
Address: _________________________________________
Date of Birth: ______________________
May 20, 1947
Social Security No: ____________________________ Home Phone: ______________ Cellphone: _____________ +63917.608.7679
Roman Catholic
Religion: _____________________ Filipino
Race: ________________ Language Spoken/Understand:__________
Chinese General Hospital
Admitted from: ________________________________ 286 Blumentrit St. District III Sta. Cruz Manila
Address: _____________________________________
Massive Pulmonary Embolism, Diabetes Milletus Type 2
Diagnosed: Medical ______________________________________________________________________________
______________________________________________________________________________
x
Is client conserve? ____conserved ____unconserved Marital Status: ______________
widowed

SUPPORTED LIVING SERVICES AGENCY INFORMATION (in case of emergency, pls. contact)
Agency Name: ________________________ Agency Address: ___________________________________
Agency Program Director: __________________________ Work Ph. _____________ Cell Ph. ____________________
Agency Nursing Consultant: _________________________ Work Ph. _____________ Cell Ph. ____________________
Request Start Date: ______________________ Discharge Date: ___________________

PLACEMENT INFORMATION
Placement Agency: ____________________________ Service Coordinator: ____________________________
Address: _____________________________________ Main line: ________________ Fax: ________________
UCI #: __________________________ MEDI-CAID Waiver: ______________________________________

FAMILY INFORMATION (in case of emergency, pls. contact)

Lourdes Irene Padilla
Name: ______________________ daugther Name:_____________________
Relationship: _________ Melissa Iloreta daugther
Relationship: _________
17 Ilang Ilang St. Marulas Valenzuela City
Address: ________________________________ Home Phone: _________________
+63917.608.7679

PHYSICAL DESCRIPTION
173cm
Height: ___________ 72kgs
Weight: __________ x
Sex: ___M ___F
x
Ambulatory Status: ____Ambulatory ____Non-ambulatory x
Speech ____Verbal ____Non-verbal
PPSV23 Vaccine (Pneumococcal Polysaccharide Vaccine - Feb2020 , INFLUENZA (FLU) Vaccine -Jan 2021
Imunization: _______________________________________________________________________________________

INSURANCE INFORMATION ________________________________

MR #: _______________ ________________________________

MEDICAL PROVIDERS
Dr. Alvin Dela Cruz
PC Physician: ________________________ Every 3months
Visits: ______________________________
Room 719 CGH Hospital,MAB +63920.6233146
Address: ____________________________________ Telephone: _________________ Tues- Thurs 3PM-5PM
Appts: ______________
_____________________________________
286 Blumentrit Stacruz Manila
Dr. Rebecca Alba
Endocrinologist: ___________________________ +63932.8519627
Telephone: ________________ Tues- Thurs, Sat 1PM-5PM
Appts: ______________
Room A6 Medical Arts Pavilion
Address: _________________________________,CGH Fax: _______________ Appts: _______________
286 Blumentrit Sta Cruz Manila
_____________________________________
Dr. Bernice Ong
Pulmonary Medicine: ________________________________ +63917.1022393
Telephone: __________________________
_________________________________ For Emergency: _____________________
MERCURY DRUGS -MCU
Pharmacy: ___________________________ Telephone: +63919.080.6381
___________________
MEDISCOUNT -BANAWE
_________________________________ +63917.3108484
Telephone:_______________
CHINESE GEN-PHARMACY
_________________________________ 871.4141 to 44
Telephone: __________________ Appts: ____________

CHINESE GENERAL HOSPITAL

Name of Hospital: ________________________________
286 Blumentrit St. District III Sta. Cruz Manila
Hospital Address: _________________________________
__________________________________ 8711-4141 to 44
Tel: ___________________
none
Allergies: ______________________ Appts: ___________________

419 EDSA Brgy 87 Caloocan City 8366-3975

 Asian Caregiving and Technology Education Centers, Inc

CURRENT LIST OF MEDICATIONS:

Brief Client Description: PULMONARY EMBOLISM WITH TYPE 2 DIABETES MILLETUS

1. Insulin Glargine (Teujeo) 12units once a day every 8pm ( pls note if fasting sugar <100 decrease to 8units)
2. Insulin Glulicine (Apidra) ( for blood sugars >180 before meal Inject 4units)
3. Vildagliptin (Galvuz Met) 50mg/tab –(Take one tab 2x a day am/pm)
4. Pantoprazole (Pantoloc) 40mg/tab –(Take one tab once a day before bedtime)
5. Rosuvastatin (Creztor) 10mg/tab –(Take one tab once aday day at bedtime )
6. Amplodepine ( Amzef) 5mg/tab (take one tab once a day in the morning)
7. Apixaban (Apixazen) 5mg /tab (Take 2 tablets everyday am/pm)
8. Budesonide-Formetorol Rapihaler (Symbicort) 160mcg/4.5mcg (Take 2 puffs 2x aday, gargle after use)
9. Daflon 500mg –(Take one tab once a day before bedtime) start June 26, 2021 stop Heparin Injection.

419 EDSA Brgy 87 Caloocan City 8366-3975