Keeping track of your health information can be difficult ...
[Pages:2]MY HEALTH R?SUM?
Keeping track of your health information can be difficult. In order to make communicating with your healthcare provider easier, it's important to keep a r?sum? of all your important health information. Please fill out this document before your next doctor visit. If you don't have all the details, it's OK, just ask your healthcare professional for the missing information during your visit.
PERSONAL INFORMATION
Name (first and last)
Date of birth
Gender
Health measurements
Height
Weight
Glucose Level
Blood Pressure
Total cholesterol ((LDL-cholesterol, HDL-cholesterol)
Medications (includes prescriptions, over-the-counter medicines, and vitamins)
Name of medication(s)
Dosage(s) Frequency (example: once-daily, twice daily) Reason for medication(s)
Allergies or sensitivities to medications or materials (such as latex), and food (please list)
Immunizations (date of last administration)
Flu shot
Pneumonia
Hospitalizations and surgeries (please list)
Other (please list)
Family Medical History (please note any conditions in your family)
Grandparents
Parents
Siblings
Children
Contact Information Home Address Phone Number Emergency Contact Information Name
Email Address Phone Number
PRIMARY CARE PHYSICIAN INFORMATION
Name of Primary Care Physician
Address of Primary Care Physician
Phone Number of Primary Care Physician
INSURANCE INFORMATION
Insurance Provider
Policy Number
Phone Number
PREFERRED PHARMACY INFORMATION
Name of Preferred Pharmacy Address of Preferred Pharmacy Phone Number of Preferred Pharmacy
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