4 Areas To Cover in Your Medical History Data Sheet

Bring a copy of this to all 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, either away from home or online.

Download the free My Personal Medication Record pdf from the AARP  in English or Spanish. Complete one form for each family member, and update as needed.

While you’re gathering information, complete the My Family Health Portrait from the Surgeon General’s Office for background information on family illnesses and diseases.

In addition, download and complete our Medical Appointment Tracking Form. This can help track each doctor, medication, tests and so on. After each appointment, add all medical notes to your personal medical folder.

Emergency Information Sheet

Your Name___________________________________________________

Address_____________________________________________________

Phone Number________________________________________________

Date of Birth__________________________________________________

Social Security Number___________________________________________

Emergency Contact_______________________________________________

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_____________________________________________________

Health Conditions______________________________________________

Current Medications_____________________________________________

____________________________________________________________

____________________________________________________________

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                                             ______________________________________________

Other                                                 ______________________________________________

Other                                                 ______________________________________________

 

Tuberculosis (test)

Date:                  Results:

__________________________________________________________

Date:                   Results

__________________________________________________________


Remember…

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.