Personal Health Information Record

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Personal Health Information Record Powered By Docstoc
					 Your Contact Information

NAME: _________________________________________________________________________________________

Date of Birth: ___/___/___ Male ___ Female ___ Date last updated (aim to update form every year): _____________

Home Address: _________________________________________________________________________________

City: ________________________________________ State: ____________ Zip:_____________________________

Phone Number: _____________________________________ E-mail: ______________________________________

Parent/Guardian/Other Support Person: _____________________________________________________________

Phone Number/Other Contact Information: __________________________________________________________

Relationship: ____________________________________________________________________________________


 Your Health Care Providers

Primary Care Physician: __________________________________________________________________________

Location: __________________________________ Phone Number: ______________________________________

Specialist Physician/Other Health Care Provider: ______________________________________________________

Location: __________________________________ Phone Number: ______________________________________

Specialist Physician/Other Health Care Provider: ______________________________________________________

Location: __________________________________ Phone Number: ______________________________________

Dentist: _________________________________________________________________________________________

Location: __________________________________ Phone Number: ______________________________________

Preferred Pharmacy: ______________________________________________________________________________

Location: __________________________________ Phone Number: ______________________________________

 Your Insurance
Employer: ______________________________________________________________________________________

Insurance Provider (attach copies of insurance cards): ___________________________________________________

Policy Number: _____________________________ Phone Number: ______________________________________

Dental Insurance Provider: ________________________________________________________________________

Policy Number: _____________________________ Phone Number: ______________________________________

Pharmacy Insurance Provider: _____________________________________________________________________

Policy Number: _____________________________ Phone Number: ______________________________________
                                                                               www.PlanforYourHealth.com
 Your Medications
Active Medications and Prescription Information (attach copies of all active prescriptions):

Medication: _____________________________________________________________________________________

Prescription Number: _____________________________________________________________________________

Instructions/Dosage: _____________________________________________________________________________

Medication: _____________________________________________________________________________________

Prescription Number: _____________________________________________________________________________

Instructions/Dosage: _____________________________________________________________________________

Glasses ______ Contact lenses _________

Prescription: ____________________________________________________________________________________

Brand (contact lenses): ___________________________________________________________________________


 Your Health History
Medical Conditions: ______________________________________________________________________________

Blood Type: _____________________________________________________________________________________

Allergies: _______________________________________________________________________________________

Diet Restrictions: ________________________________________________________________________________

Immunizations (attach copies of immunization records, including dates): ____________________________________

 _______________________________________________________________________________________________

Recent Laboratory Results (for example, blood tests and results of mammograms and pap smears): ______________
 _______________________________________________________________________________________________

Recent Hospitalizations (include dates): ______________________________________________________________
 _______________________________________________________________________________________________

Recent Surgeries (include dates): ___________________________________________________________________
 _______________________________________________________________________________________________


 Your Pet’s Health

Veterinarian: _______________________________ Phone Number: ______________________________________

Immunizations (attach copies of immunization records): __________________________________________________

Other Pet Health Information: ______________________________________________________________________

                                                                                    www.PlanforYourHealth.com

				
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