MY PERSONAL HEALTHCARE RECORD. A great way to keep your. healthcare & medication. information in one place. Remember to take this
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1 A great way to keep your MY PERSONAL HEALTHCARE healthcare & medication information in one place RECORD Remember to take this with you to all of your hospital & doctor visits Our Community Your Health
2 PERSONAL INFORMATION THIS PERSONAL HEALTHCARE RECORD BELONGS TO: Address Home Work Cell Date of Birth (month/date/year) EMERGENCY CONTACTS Relationship Home Work Cell Relationship Home Work Cell PRIMARY CARE PROVIDER Address Fax INSURANCE COMPANY/TPA Policy or Group # ID or Member # ORGAN DONOR? q Yes q No MEDICAL POWER OF ATTORNEY Relationship Date of Document Location of Document LIVING WILL Attorney Date of Will Location of Will PREFERRED HOSPITAL Address PREFERRED PHARMACY Address ALLERGIES (list drugs & food) IMMUNIZATIONS (list date last received) Influenza (Flu) Vaccine / / Tetanus Vaccine / / Pneumococcal (Pneumonia) Vaccine / / Hepatitis Vaccine Meningitis Vaccine Zoster (Shingles) Vaccine / / / / / / Other / / Other / / Other / / 2 3
3 PHYSICIAN INFORMATION MEDICAL CONDITIONS SPECIALTY NAME PHONE LAST SEEN CHECK ALL THAT APPLY SINCE (YR) Primary Care (Family Physician/Internist) Allergist (Allergies) Cardiologist (Heart) Dentist Dermatologist (Skin) Endocrinologist (Glands, Hormones) Gastroenterologist (Stomach, Bowel) Infectious Disease Neurologist (Nervous System) Obstetrics/Gynecology (Childbirth, Female) Occupational Medicine (Worker s Comp) Oncologist & Hematologist (Cancer & Blood) Ophthalmologist (Eye) Orthopedist (Bones, Joints) Otolaryngologist (Ear, Nose & Throat) Physiatrist (Physical Therapy) Podiatrist (Feet) Pulmonologist (Lung) Rheumatologist (Arthritis, Autoimmunity) Surgeon (General, Plastic, Vascular) Urologist (Urinary System, Male) Other: q Abnormal Heart Beat (Irregular Heart Rhythm, Atrial Fibrillation) q AIDS/HIV q Alzheimer s or Dementia q Asthma q Auto-Immune Disease (Rheumatoid Arthritis, Lupus, Multiple Sclerosis) q Cancer q Chronic Obstructive Pulmonary Disease (COPD) or Chronic Bronchitis q Congestive Heart Failure q Coronary Artery Disease (CAD) Bypass Graft? q Yes q No Stent? q Yes q No q Depression, Anxiety q Diabetes Insulin Dependent? q Yes q No q Frequent Chronic Pain (circle all that apply) Back Neck Knee Other q GERD (Gastro-Esophageal Reflux Disease) q Gastrointestinal Problems (Inflammatory Bowel Disease, Crohn s, Ulcers) q Heart Attack (MI or Myocardial Infarction) q High Blood Pressure (Hypertension) q High Cholesterol q Hypothyroidism q Kidney and/or Prostate Problems q Obesity q Osteoarthritis q Pacemaker q Seizure Disorder q Stroke (CVA or Cerebral Vascular Incident) q Transient Ischemic Attacks (TIA s) or Carotid Artery Disease q Other (please list) 4 5
4 DATE ADMITTED HOSPITALIZATIONS, SURGERIES & ER VISITS DATE DISCHARGED HOSPITAL & LOCATION REASON DATE OF VISIT URGENT CARE & WALK-IN CLINIC VISITS FACILITY & LOCATION REASON FOR VISIT OTHER HEALTH ACTIVITIES v Health Education Classes for: v Dietician for: v Physical Therapy for: v Counseling for: v Pain Management for: v Occupational Therapy for: v Acupuncture for: v Chiropractor for: v Massage Therapy for: v Other for: v Other for: v Other for: v Other for: 6 7
5 CURRENT MEDICATION & SUPPLEMENT RECORD MEDICATION/SUPPLEMENT DOSE HOW MANY HOW I TAKE IT WHEN I TAKE IT [ 4] REASON I TAKE IT PRESCRIBED BY START DATE END DATE Example: Lisinopril 10 mg 1 By mouth with breakfast High Blood Pressure Dr. Smith 11/2011 Still Taking 8 9
6 PREVENTIVE SCREENINGS OTHER TESTS & LAB WORK Female Breast Exam Date of Last Physician/Facility Results Keep track of additional tests and lab work recommended by your doctors/providers here. Mammogram Pelvic/Cervical Exam Pap Smear Bone Density (DEXA SCAN) Colonoscopy Dental Check-Up Eye Exam Hearing Exam Other: Other: Other: Date Test Physician/Lab Results Male Testicular Exam Date of Last Physician/Facility Results DRE Digital Rectal Exam Prostate Exam Colonoscopy Dental Check-Up Eye Exam Hearing Exam Other: Other: Other: My Current... Height Weight Blood Pressure / Pulse Waist Circumference Body Mass Index (BMI) Other: 10 11
7 PERSONAL HEALTH GOALS Answers to the following questions will help you establish what s most important to you on your healthcare path. What is one health-related issue that is important to me and I would like to improve upon? What specifically would I like to do to address this issue? WHEN YOUR DOCTOR S OFFICE IS CLOSED & YOU NEED HELP Even if your doctor s office is closed, there is always a physician who is on call to answer your questions and point you in the right direction. You can also call your primary care provider when you are unsure of the severity of your condition. Again, even if the office is closed you will be told how to contact the on-call doctor directly. Use the examples in the following chart to help you determine when to call your doctor s office, go to the nearest emergency room or call 911. Is this something I can realistically accomplish? Can I think of any barriers to being successful at accomplishing this? If this is not realistic, how can it be broken down into smaller parts so I can start with just one small piece? How much time would I like to spend each time I do this? How often would I like to do this? Starting when? CALL YOUR PRIMARY CARE PROVIDER IF YOU HAVE... Colds, Cough or Sore Throat Diarrhea or Upset Stomach Earaches Eye, Sinus or Urinary Tract Infections Fever or Flu Symptoms Minor Burns or Cuts CALL 911 OR GO DIRECTLY TO THE EMERGENCY ROOM IF YOU HAVE Head Injuries Life or Limb Threatening Conditions Loss of Consciousness Major Burns Poisoning Severe Bleeding How long do I think it will take for this activity to become a regular part of my life? What will encourage me to stay on track with this goal? Skin Rashes Sprains Severe Chest/Abdominal Pain Sudden Speech Loss or Arm/Leg Numbness When I stumble with my goal, what will keep me from getting discouraged so that I can start anew, right where I left off? What will tell me I have succeeded in my goal? IF YOU NEED MEDICAL CARE THAT IS NOT AN EMERGENCY, REMEMBER TO CALL YOUR PRIMARY CARE PHYSICIAN FIRST, EVEN AFTER THE OFFICE IS CLOSED 12 13
8 NOTES/QUESTIONS & ANSWERS NOTES/QUESTIONS & ANSWERS 14 15
9 YOUR BEST HEALTH HISTORIAN IS YOU USE THIS PERSONAL HEALTH RECORD TO BETTER MANAGE YOUR HEALTH & KEEP ALL OF YOUR INFORMATION TOGETHER IN ONE PLACE v Take this Health Record to all of your doctor visits and other health-related activities and facilities. v Keep your information current by making updates or changes to any of the sections whenever necessary, especially changes to your medication list. v Use only pencil to keep your medical record easy to update. v Inform your primary care provider about additional healthcare providers you have seen, especially if they have ordered medications or treatments he/she may not know about. v Inform your primary care provider about other healthcare facilities you have recently visited, especially any hospitalizations, emergency room visits or urgent care visits that he/she may not otherwise know about. Boulder Valley CARE NETWORK 6676 Gunpark Dr., Suite B Boulder, Colorado Boulder Valley Care Network. All rights reserved. This material was adapted by the Boulder Valley Care Network (BVCN) from the Personal Health Record developed by Dr. Eric Coleman, UCHSC, HCPR, and also developed by IPRO, the Medicare Quality Improvement Organization (QIO) for New York State. The contents do not necessarily reflect the policy of any organization other than BVCN
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. Norman J. Brodsky, M.D. Board Certified Michael D. Gauwitz, M.D. Diplomate, ABR Taghrid A. Altoos, M.D. Radiation Oncology Hiral K. Shah, M.D. PATIENT HEALTH INFORMATION SHEET NAME: DATE OF BIRTH: AGE:
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
OhioHealth Orthopedic & Sports Medicine Physicians
Page 1 of 6 OhioHealth Orthopedic & Sports Medicine Physicians 335 Glessner Avenue, Mansfield, Ohio 44903 PATIENT INTAKE ASSESSMENT OFFICE USE ONLY Fax to: OR Control 419-520-2831 For Joint Replacement
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
Please complete and return to the office prior to your appointment.
Please complete and return to the office prior to your appointment. Name: Last:, Today s Date: First: MI: Nickname: Date of Birth: Age: Sex: M F SSN: Parent/Legal Guardian (if the patient is a minor):
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM
MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM Name: Date Reason for Consultation: Physicians involved in your care: Best Contact Phone #: Can we leave a message: YES NO
New Patient Paperwork
New Patient Paperwork Date: Phone: Patient: Last Name First Name Initial Street Address: City/State/Zip Code: Sex: M F Age: Birthdate: Single Married Widowed Separated Divorced Email: Newsletter? Y N Insured
PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT
Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
SCHNEIDER MEDICAL GROUP, PA History Intake Form (Please Print)
History Intake Form Patient Name: Date of Visit: Briefly State the reason for the visit: Date of Birth: Physician Use Only - History and Present: 1. 2. 3. 4. 5. Page 1 of 10 Review of Symptoms HEAD NO
BARIATRIC PROGRAM PREVIOUS BARIATRIC SURGERY HEALTH QUESTIONNAIRE (PLEASE PRINT CLEARLY)
BARIATRIC PROGRAM PERSONAL INFORMATION PREVIOUS BARIATRIC SURGERY HEALTH QUESTIONNAIRE (PLEASE PRINT CLEARLY) Name: Date: Sponsor s SSN# - - Date of Birth: Age: Mailing Address: City: State: Zip: Mobile
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
PATIENT HEALTH HISTORY
DEMOGRAPHICS Name: Date of Birth: Sex: Male Female Ethnicity (optional): Hispanic or Latino Not Hispanic or Latino Race (optional): White Black or African American Other: PREFERRED LANGUAGE Is English
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Reason for visit: Previous and/or Maiden Name: Parent/Guardian Name if patient is minor: Birth date: (M/D/Yr) Gender: Male Female SSN (patient): SSN (guardian, if patient is minor):