Personal Health Record

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What kind of information would you put in a personal medical record? You could start with 

   * Your name, birth date, blood type and emergency contact
   * Date of last physical
   * Dates and results of tests and screenings
   * Major illnesses and surgeries, with dates
   * A list of your medicines, dosages and how long you've taken them
   * Any allergies
   * Any chronic diseases
   * Any history of illnesses in your family


  • Always take your updated Medication Form. This will tell your doctor everything you are taking, including prescription medicines, over-the-counter medicines, and herbals.
  • Tell your doctor about any allergies or reactions that you have had to medicine in the past.

Personal Health Record Form

Name:

Age:

Sex:

Blood Group:

Contact Address:

Contact Telephone Numbers:

Emergency Contact Address:

Emergency Contact Numbers:


Dental Records:

Immunization History:

Medications:

Drug:

Brand Name:

Dosage:

Duration:

Start Date:

End Date:

Comments:

Allergies

Drugs:

Environmental:

Food:


Symptom Diary

Important Symptoms to Describe to Your Doctor, With Your Next Medical Visit

General

__ Fever

__ Weight Loss

__ Night Sweats

__ Fatigue

__ Weight Gain

__ Excessive Thirst

__ Daytime Sleepiness

__ Insomnia

__ Lack of Concentration


Head

__ Severe Headache

__ Headache Worse at Night

__ Dizziness or Loss of Balance

__ Pins and Needles over Head or Face

__ Loss of, or Blurred Vision

__ Ringing in Ears or Loss of Hearing


Neurological

__ Tingling or Burning

__ Loss of Strength

__ Shakiness

__ Memory Loss

__ Feeling Depressed

__ Extreme Nervousness

__ Suicidal Thoughts



Chest

__ Chest Pain

__ Chest Pain, Worse With Exercise

__ Shortness of Breath

__ Irregular Heart Beat

__ Cough for at Least a Month

__ Bloody Sputum


Digestive

__ Difficulty Swallowing

__ Persistent Heartburn, or Nausea

__ Abdominal Pain

__ Bloody or Black Stools

Genito Urinary

__ Excessive Urination

__ Pain With, or Blood in Urine

__ Urine Incontinence

__ Painful Intercourse

__ Loss of Sexual Desire

__ Breast Pain &/or Lump

__ Heavy &/or Painful Menstruations

Skin

__ New mole

__ Changing Skin Blemish

__ Sore That Won’t Heal

__ Itchiness

__ Rash


Blood Pressure

Date:

Reading: Systolic/Diastolic :

Supine/Sitting position:


Blood Sugar

Date:

Reading:

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