Personal Health Record - Template For Adults

Health Information Form-for Adults
A. Identification
Name (Last)
B. Emergency Contacts
(First)
(Middle)
Maiden Name
Contact
Name (last)
(Middle)
Relationship
Primary Address
City
State
Zip
Country
Alternate Address
City
In Case of Emergency, Notify: Primary
State
Country
Home Phone
Work Phone
Cell Phone
Email Address
Date of Birth
Address
City
Zip Code
Sex:
Male
(First)
State
Home Phone
Country
Work Phone
Cell Phone
Female
Zip Code
Email Address
In Case of Emergency, Notify: Secondary

Contact
Height
Weight
Race
Eye Color
Hair Color
Birthmark/Scars
Blood/RH Type
Special Conditions
Name (last)
Name (middle)
Name (first)
Relationship
Marital
Status
Address
Occupation
City
Company Name
Home Phone
Work Phone
Cell Phone
Email Address
City
State
Phone Number
Zip Code
Country
Languages Spoken
Primary Health
Insurance Carrier
Policy Number
Secondary Health
Insurance Carrier
Policy Number
State
Zip Code
Country
In Case of Emergency, Notify: Medical Contact

Doctor (Indicate Specialty)
Phone Number
C.
Dentist
Telephone Number
Pharmacy
Telephone Number
Phone
Emergency Phone No.

(after hours)
Healthcare Provider
Healthcare Provider
Specialty
Primary Care Physician

Yes
No
Name
Email Address
Group or Association
Fax
Address
Web Address/URL
City
State
Healthcare Provider
Specialty
Zip Code
Country

Yes
No
Phone
Name
Email Address
Fax
Address
Web Address/URL
City
State
Healthcare Provider
Specialty
Zip Code
Country

Yes
No
Phone
Name
Email Address
Fax
Address
Web Address/URL
City
State
Healthcare Provider
Specialty
Zip Code
Emergency Phone No.

(after hours)
Emergency Phone No.

(after hours)
Country

Yes
No
Phone
Emergency Phone No.

(after hours)

Name
Email Address
Fax
Address
Web Address/URL
City
D.
State
Zip Code
Country
Insurance Providers
Insurance Provider Type
E-mail Address
Company Name
Web Address/ URL
Address
Primary Insured
Person-Name
Name of Employer
City
State
Zip Code
Country
Contact Name
Phone
Address
Identification-Group
Number
Contact InformationPhone
Member(ID) Number
City
Emergency Phone No.

(after hours)
Phone Number
Fax
State
E-mail Address
Company Name
Web Address/ URL
Address
Primary Insured
Person-Name
Name of Employer
City
State
Zip Code
Country
Phone
Address
Number
Member(ID) Number
City
Emergency Phone No.

(after hours)
Phone Number
State
E-mail Address
Company Name
Web Address/ URL
Address
Primary Insured
Person-Name
Name of Employer
State
Zip Code
Country
Zip Code
Country
Fax
Contact-Name
City
Social Security No.
Social Security No.
Zip Code
Country
Fax
Social Security No.

Contact-Name
Phone
Address
Number
Member(ID) Number
City
Emergency Phone No.

(after hours)
Phone Number
State
Zip Code
Country
E. Legal Documents/Medical Directives

Living Will
Durable Power of Attorney for
Healthcare
Power of Attorney
Document Location (Physical Location)
Fax
Location Name (for example Bank of America)
Contact (Name of person who has access to the

document)
Address
Address
City
City
State
Zip Code
Country
State
Zip Code
Country
Contact Information
Legal Representative (Name of person who you

have assigned legal authority)
Home Phone
Address
Pager
E-mail Address
Work Phone
Work E-mail Address
City
State
Zip Code
Country
Contact Information
Cellular Phone
Fax
Home Phone
Cellular Phone
Date Filed
Pager
E-mail Address
Organ Donation:
Work E-mail Address
Work Phone
Organ Donor
Yes
No
Living Will
Durable Power of Attorney for
Healthcare
Power of Attorney
Document Location(Physical Location)
State Where Registered
Fax
Location Name (for example Bank of America)
Contact ( Name of person who has access to the

document)
Address
Address
City
City
State
Zip Code
Country
Legal Representative (Name of person who you

have assigned legal authority)
State
Zip Code
Country
Contact Information
Home Phone
Cellular Phone

Address
City
State
Zip Code
Country
Contact Information
Pager
E-mail Address
Work Phone
Work E-mail Address
Fax
Home Phone
Cellular Phone
Date Filed
Pager
E-mail Address
Organ Donation:
Work E-mail Address
Work Phone
Organ Donor
Yes
State Where Registered

No
F. Medical History(Check appropriate)

Acquired Immunodeficiency
Sndrome(AIDS) or HIV Positive:
Arthritis
Asthma
Bronchitis
Cancer
Chlamydia
Diabetes
Dizziness
Emphysema
Epilepsy
Eye Problem
Fainting
Frequent or Severe Headaches
Glaucoma
Date of
Onset
Date of
Onset
High Blood Pressure
Hypoglycemia
Jaundice
Kidney Disease
Low Blood Pressure
Mental Retardation
Pain or Pressure in Chest
Palpitations
Periods of unconsciousness
Rheumatic Fever
Rheumatism
Seizures
Shortness of Breath
Stomach Liver or Intestinal
Problems
Syphilis
Tuberculosis
Tumor
Thyroid Problems
Urinary Tract Infection
Other
Gonorrhea
Hearing Impairment
Heart Condition
Hemodialysis
Herpes
High Blood Cholesterol
G. Infectious Diseases
Disease
Chicken Pox
Hepatitis
Age
Date
Remarks

Measles
Mumps
Pertussis /Whooping Cough
Pneumona
Polio
Rubella
Scarlet Fever
Other
H. Immunizations
Immunization for
Diptheria
Hepatitis B
Measles
Mumps
Pertussis/Whooping Cough
Polio
Rubella
Smallpox
Tetanus
Tuberculosis
Typhoid
Other
Booster 1
Age
Date
Booster 2
Age
Date
Booster 3
Age
Date

I. Allergies/Drug Sensitivities
Allergy/Sensitivity Type
(include medications foods
environmental or other)
Reaction
Date last Occurred
Treatment

J. Family Member History
Mother
Enter ages of relatives
If deceased, indicate age and
cause of death
Check all items that apply for
their present state of health or
any illnesses they have had
Alcoholism
Arthritis
Asthma
Cancer
Diabetes
Emphysema
Glaucoma
Heart Condition
Hemodialysis
Hepatitis
High Blood Cholestrol
High Blood Pressure
Kidney Disease
Mental Retardation
Rheumatic Fever
Seizures
Smoking
Stomach Liver or Intestinal
Problems
Stroke
Thyroid Disorders
Tuberculosis
Tumor
Other
Father
Sibling(s
Grandparen
Childre

K. Lifestyle
Alcohol
Drink(s) Per Week
Number of Years
Smoking
Pack(s) Per Day
Number of Years
Exercise
Type(s) of Exercise
Days Per Week
L. Health Log
Date
Diagnosed
(Noninfectious major illnesses. Include pregnancies and childbirth)
Doctor
Nature of
Health
Problems
Age at
Onset
Condition
Status
Remarks (Such as,

medications, special
tests, x-rays, length
of hospital stay,
surgery and so on)

M. Medications
Note: Include all prescription medications, (such as nitroglycerin) over-the-counter medications (taken on a regular basis),
vitamin supplements, and herbal remedies
Date
Medication / Dosage
Frequency

N. Doctor Visits
Date
Doctor
Reason
Diagnosis

O. Hospitalizations
Hospitalization Type (includes emergency room
visits)
Admission Date
Discharge Date
Diagnosis
Doctor
Hospital
Reason
Complications

visits)
Admission Date
Admission Date
Diagnosis
Doctor
Hospital
Reason
Complications

visits)
Admission Date
Discharge Date
Diagnosis
Admission Date
Doctor
Hospital
Reason
Complications

P. Surgeries
Date
Doctor
Results
Hospital
Surgical Procedure
Description
Date
Comments
Doctor
Results
Hospital
Surgical Procedure
Description
Date
Comments
Doctor
Results
Hospital
Surgical Procedure
Description
Comments

Q. Lab or Imaging
(Examples: X-ray, MRI, Mammogram)
Test Type
Date
Test Type
Date
Requesting Doctor
Administered by
Requesting Doctor
Administered by
Reason
Reason
Result
Result
Test Type
Date
Test Type
Date
Requesting Doctor
Administered by
Requesting Doctor
Administered by
Reason
Reason
Result
Result
R. Medical Devices
(Examples: pacemaker, insulin pumas, breathing devices)
Device Type
Doctor
Device Type
Doctor
Hospital
Date
Hospital
Date
Reason
Reason

S.Physical/Occupation Therapy
Therapy Type
Start
Date
Stop Date
Frequency
Therapist

T. VISION
Date of Visit
Physician
Vision RX
Date of Visit
Date of Visit
Physician
Vision RX
Physician
Vision RX
Date of Visit
Physician
Vision RX
U. Dental Health
Date of Visit
Dentist
Problems
Resolution

Personal Health Record - Template For Adults

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Health Information Form-for Adults

In Case of Emergency, Notify: Primary

In Case of Emergency, Notify: Secondary

In Case of Emergency, Notify: Medical Contact

Health Information Form-for Adults

Emergency Phone No.

Primary Care Physician

Primary Care Physician

Primary Care Physician

Emergency Phone No.

Emergency Phone No.

Primary Care Physician

Emergency Phone No.

Health Information Form-for Adults

Insurance Provider Type

Web Address/ URL

Emergency Phone No.

Insurance Provider Type

Web Address/ URL

Emergency Phone No.

Insurance Provider Type

Web Address/ URL

Social Security No.

Social Security No.

Social Security No.

Health Information Form-for Adults

Emergency Phone No.

E. Legal Documents/Medical Directives

Location Name (for example Bank of America)

Contact (Name of person who has access to the

Legal Representative (Name of person who you

Work E-mail Address

Work E-mail Address

State Where Registered

Location Name (for example Bank of America)

Contact ( Name of person who has access to the

Legal Representative (Name of person who you

Health Information Form-for Adults

Work E-mail Address

Work E-mail Address

State Where Registered

F. Medical History(Check appropriate)

Health Information Form-for Adults

Health Information Form-for Adults

Date last Occurred

Health Information Form-for Adults

Health Information Form-for Adults

Drink(s) Per Week

Pack(s) Per Day

Days Per Week

(Noninfectious major illnesses. Include pregnancies and childbirth)

Remarks (Such as,

Health Information Form-for Adults

Health Information Form-for Adults

Health Information Form-for Adults

Hospitalization Type (includes emergency room

Hospitalization Type (includes emergency room

Health Information Form-for Adults

Health Information Form-for Adults

(Examples: X-ray, MRI, Mammogram)

(Examples: pacemaker, insulin pumas, breathing devices)

Health Information Form-for Adults

Health Information Form-for Adults