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
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
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
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
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
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
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
NOTES/QUESTIONS & ANSWERS NOTES/QUESTIONS & ANSWERS 14 15
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 80301 303.530.3405 www.mybvcn.org 2012 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. 032012