Medical History and Vaccinations Data Sheet

Bring a copy of this to medical appointments, especially if you are meeting with a new physician or specialist. Update your history as needed and store extra copies in a safe place (choose one away from your home).

For a detailed health tracking, this form from the University of Texas is for you.

In addition, print and fill in a Medical Appointment Information form. This can help track each doctor, medication, tests and so on. After each appointment, add all medical notes to your personal medical folder.

PDF version of the form below.

Emergency Information Sheet
Your Name
Date of Birth
Social Security Number

Health Insurance Information
Company
Phone
Policy Holder’s Name
Policy Number

Your Medical History (date and nature of illnesses, surgeries)
Illness and Date
Illness and Date
Illness and Date
Illness and Date
Allergies

Vaccinations

Not all listed vaccinations are required or necessary to have more than once.

Type Date #1 Date #2 Date #3 Date #4
Chickenpox (Varicella)
DTP
(Diphtheria, Tetanus, Pertussis)
Hepatitis A
Hepatitis B
Influenza
Meningococcus
MMR
(Measles, Mumps, Rubella)
Polio
Rabies
Tetanus
Tuberculosis (test) Date: Results: Date: Results
Other
Other

The information provided here is not meant to be a substitute for professional medical advice. These tips are from doctors, nurses and people who have shared their real life advice; always check with a doctor or other appropriate medical professional you trust before making any healthcare changes.

Updated: 5/2009