PNH/AA Patientenpass englisch

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Stiftung zur Hilfe bei PNH/AA

PNH/AA

Paroxysmal nocturnal hemoglobinuria / aplastic anaemia

patient pass


The bearer of this pass has PNH, AA/PNH or AA.

Der Inhaber dieses Patienten-Passes hat PNH, AA/PNH oder AA.

Le propriétaire de ce passeport a une HPN, AA/HPN ou AA.

Il portatore di questo passaporto è EPN, AA/EPN o AA paziente.

El portador de este passaporte es HPN, AA/HPN o AA paciente.

Attending family doctor / GP (stamp):

Clinic / specialized hospital (stamp):

2


Holder of this pass:

first name/surname: .................................................................................................

adress: ...........................................................................................................................

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telephone/fax: ............................................................................................................

email-adress: ..............................................................................................................

In case of an emergency please notify:

1. first name/surname: ............................................................................................

adress:.............................................................................................................................

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telephone/fax: ............................................................................................................

2. first name/surname: ............................................................................................

adress:.............................................................................................................................

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telephone/fax: ............................................................................................................

Please carry this pass with you at all times!

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Clinical data:

disease: PNH AA AA/PNH

gender: m f

date of birth:................................................................................................................

high: .......................................................... inch

weight: ...................................................... pounds date........../............../................

year of diagnosis: .................................

other diseases: ...........................................................................................................

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topical medication: ...................................................................................................

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special medication:

Steroides

Eculizumab

Cyclosporine

Danazol (androgene-therapy)

Anticoagulation.................................................................................................

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Known allergies/adverse effects: ........................................................................

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Port-a-cath: yes no

Primary hematologist:

(Please contact in case of emergency as soon as possible)

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email-adress: ..............................................................................................................

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In case of emergency please follow this advice:

AA and PNH are rare diseases, which show sometimes unexpected,

atypical and sudden symptoms. As these symptoms may be signs of

a critical underlying disease specific event, we strongly recommend

consulting an experienced hematologist during an emergency!

Please be especially alert if any of the following symptoms occur:

• sudden pain

• signs of infection

• neurological symptoms

• bleeding-signs

• ispnoe dyspnea

• signs of circulatory disturbance or embolism

Further comments:

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More information about PNH/AA

available on the website of the

foundation Lichterzellen under

www.lichterzellen.de

Stiftung zur Hilfe bei PNH/AA

The patient pass ist an initiative of the foundation Lichterzellen.

Publisher:

Stiftung Lichterzellen

Oppenheimstraße 11

D-50668 Köln

telephone 0049-21-57 77 22 76

fax 0049-221-57 77 22 77

info@lichterzellen.de

www.lichterzellen.de

Medical advice:

Prof. Dr. Tim Brümmendorf, Dr. Jens Panse

Klinik für Onkologie, Hämatologie und Stammzelltransplantation

Universitätsklinikum Aachen

Euregionales comprehensive Cancer Center Aachen (ECCA)

© Copyright 2014

Disclaimer:

The publisher assumes no liability or guarantee for the topicality, correctness

and completeness of the content of this document. The use of the content of this

document is at the user´s own risk. With the use of the content of this

document create any contractual relationship between the user and the publisher is

established.

If you have comments or suggestions for improving patient pass or

want reorder these free, send us an email with the

heading „patient pass“ at info@lichterzellen.de.

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www.lichterzellen.de

PP 2014-01

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