Making a Personal Medical History Chart - Caregivers Library

[Pages:3]Makin g a Pe rs o n al Me d ical H is to ry Ch art

A s a m p le ch a r t t o h e lp y o u d o cu m e n t y o u r lo v e d o n e 's m e d ica l h is t o r y .

In addition to the doctor's medical history chart, a personal health history is an excellent resource, as it provides a consolidated history of all medical care and conditions over a stated period of years. Doctors find this information especially useful--even critical--when prescribing drugs or preparing treatment plans. It can alert them to any complications that might exist based on previous conditions or medications.

Your Loved One's Personal Healt h History

Use this form to keep track of your loved one's health history. Print out a copy and take it with you to your doctor appointments to help keep your doctor up to date

Full Name:

Date of Birth:

I w as in the hospital for ( list conditions) :

Date

For addit ional t ools for caregiving or aging, visit

I have had these surgeries: I have had these injuries/ conditions/ illnesses:

Date Date

I have these allergies:

Date

For addit ional t ools for caregiving or aging, visit

I have had these immunizations(shots): Suggested age Date(s) received Influenza Every year starting at age 65 __________ Pneumococcal Once at age 65 __________ Tetanus (Td) Every 10 years __________ I take the following medicines/supplements:

My family members (parents, brothers, sisters and grandparents) have/had these major conditions:

I see these health care providers: (List provider's name and condition treated.)

? Co pyrigh t Fa m ilyCa re Am e r ica , In c. All Righ ts Re s e rve d . Adapted fro m m aterials develo ped by the Natio nal Institutes o f Health.

For addit ional t ools for caregiving or aging, visit

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