Return PS of country A

Patient Data

Identification

National Health Care patient ID (country of affiliation):
National Health Care patient ID (country of treatment):
Other Identifier:

Personal Information

Full Name

Given name:
Family Name/Surname:
Prefix:
Suffix:
Date of Birth:
Gender:

Contact Information

Address

Street:
Number of Street:
City:
Postal Code:
State or Province:
Country:

Telecom

Telephone No:
Email:

Preferred HP to contact

Full Name

Given Name:
Family Name/Surname:
Prefix:
Suffix:
Telephone No:
Email:

Legal Organization to contact

Organization Name:
Telephone No:
Email:

Contact Person/legal guardian

Role of that person:

Full Name

Given Name:
Family Name/Surname:
Prefix:
Suffix:
Telephone No:
Email:

Insurance Information

Insurance Number:

Clinical Data

Alerts

Allergy

Allergy description:
Allergy code:
Onset Date:
Agent description:
Agent Code:

Medical Alert Information

Health Care Alert code:
Health Care Alert description:

History of Past Illness

Problem/Diagnosis

Problem/diagnosis Description:
Problem/diagnosis Id (Code):
Problem Status:
Problem Severity:
Onset Time:
End date:
Resolution Circumstances:

Vaccination

Vaccine brand name:
Vaccine description:
Vaccine code:
Vaccination date:

Surgical Procedure

Procedure description:
Procedure Id (code):
Procedure Date:

Medical Problems

Problem/Diagnosis

Problem/diagnosis Description:
Problem/diagnosis Id (Code):
Problem Status:
Problem Severity:
Onset Time:
End date:
Resolution Circumstances:

Surgical Procedure

Procedure description:
Procedure Id (code):
Procedure Date:

Medical Devices and Implants

Medical Devices and Implants Description:
Device Code:
Implant Date:

Treatments

Treatment description:
Treatment code:
Onset time:

Care plan

Recommendations Description:
Recommendations Id (code):

Disability or function

Invalidity description:
Onset time:

Medication

Prescription

Prescription identification:
Medicinal product code:
Date of issue of prescription:
Brand name:
Active ingredient:
Active ingredient code: