I will Do My Part and Take Charge of My Health.
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- Blaze Nathaniel Parsons
- 5 years ago
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2 I will Do My Part and Take Charge of My Health. I will fill this out and Take this Personal Health Record with me to all medical appointments, hospitalizations and when I travel. Bring all medications to every doctor s visit. Complete a Living Will and have a Power of Attorney for my health care. Use Ask Me 3 questions every time I talk to my doctor: 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this? Exercise regularly. Eat healthy.
3 Personal Health Record of: Name: Birth Date: / / Address: Emergency Contacts Name: Relationship: Name: Relationship: Alt. Alt. Doctors and Pharmacy Primary Doctor: Specialist: Specialist: Pharmacy: Others who provide care for me Home Health Agency: Community Services: (Example: Meals on Wheels, personal care or transportation services) My Hospital:
4 Notes and Questions about My Health My health care goal: (Example: I want to be able to take walks again with my dog): What keeps me from meeting my health goals: Questions for my doctor:
5 o Arthritis o Asthma/COPD o Cancer Type: Medical History o Surgeries (such as cataract, joint replacement, fracture, heart by-pass, gall bladder, hysterectomy, prostate, pacemaker, defibrillator) Surgery: Surgery: Surgery: Surgery: Surgery: Surgery: Surgery: o Diabetes o Heart Disease o Hepatitis/HIV o High Blood Pressure o Kidney disease o Stroke o Ulcer o Seizure Date: / / Date: / / Date: / / Date: / / Date: / / Date: / / Date: / / Immunizations & Screenings Annual Flu Vaccine Date: / / / / / / Pneumonia Vaccine Date: / / Mammogram Date: / / / / / / Colorectal Screening Date: / / / / / / Prostate Screening Date: / / / / / / Cholesterol Screening Date: / / / / / / Blood Sugar Screening Date: / / / / / / Notes:
6 Hospital Visits Hospital: Reason: Date Admitted / / Date Discharged / / Hospital: Reason: Date Admitted / / Date Discharged / / Hospital: Reason Date Admitted / / Date Discharged / / Hospital: Reason: Date Admitted / / Date Discharged / / Hospital: Reason: Date Admitted / / Date Discharged / / Hospital: Reason: Date Admitted / / Date Discharged / / Hospital: Reason: Date Admitted / / Date Discharged / /
7 Things I Need to Watch For Warning signs that my medical condition may be getting worse: Warning Signs What I need to do
8 My Medication List (including prescriptions, vitamins and over-the-counter medicines) Allergies: Name of Medication How much? When? What is it for? Start Date Example: Lasix 20 mg 1 a day morning Water pill Nov 2011
9 Cross out medications that you are no longer taking.
10 My Medication List (including prescriptions, vitamins and over-the-counter medicines) Name of Medication How much? When? What is it for? Start Date
11 Cross out medications that you are no longer taking.
12 My Medication List (including prescriptions, vitamins and over-the-counter medicines) Name of Medication How much? When? What is it for? Start Date
13 Cross out medications that you are no longer taking.
14 Doctor Appointments Date Doctor Reason
15 Hospital Checklist This is important information to know if I am hospitalized and I will complete this checklist before I leave the hospital. I have been involved in decisions about what will take place after I leave the hospital. My doctor, nurse or case manager has answered my most important questions prior to leaving the hospital. I understand where I am going after I leave the hospital and what will happen to me once I arrive: Home alone or with family Home with a home health agency follow-up At another facility for more treatment My family or someone close to me knows that I am coming home. I have the name and phone number of a person I should contact if a problem arises. I understand what my medications are, how to get them, how to take them, and possible side effects. I understand how to keep my health problems from becoming worse. I understand which warning signs I need to watch out for and whom to call if I should notice them. I have answers for how to get help at home when I need it. I have a scheduled follow-up appointment with my doctor. This material was prepared by Alliant GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 10SOW-GA-IIPC-11-23
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