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    Your Health Plan

    Uploaded by

    Maggie Fornaro
    This document provides templates for a personal health journal, including sections to record contact information for doctors and insurance, existing health conditions and treatments, current medications, medical symptoms and vital statistics, immunization history, hospitalizations and surgeries, chronic diseases and family medical history, health exams and screenings, and emergency contact information. The health journal is designed to help individuals keep comprehensive records of their health to better discuss their medical history and care with healthcare providers.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Your Health Plan

    Uploaded by

    Maggie Fornaro
    65 views9 pages
    This document provides templates for a personal health journal, including sections to record contact information for doctors and insurance, existing health conditions and treatments, current medications, medical symptoms and vital statistics, immunization history, hospitalizations and surgeries, chronic diseases and family medical history, health exams and screenings, and emergency contact information. The health journal is designed to help individuals keep comprehensive records of their health to better discuss their medical history and care with healthcare providers.

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    This document provides templates for a personal health journal, including sections to record contact information for doctors and insurance, existing health conditions and treatments, current medications, medical symptoms and vital statistics, immunization history, hospitalizations and surgeries, chronic diseases and family medical history, health exams and screenings, and emergency contact information. The health journal is designed to help individuals keep comprehensive records of their health to better discuss their medical history and care with healthcare providers.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    65 views9 pages

    Your Health Plan

    Uploaded by

    Maggie Fornaro
    This document provides templates for a personal health journal, including sections to record contact information for doctors and insurance, existing health conditions and treatments, current medications, medical symptoms and vital statistics, immunization history, hospitalizations and surgeries, chronic diseases and family medical history, health exams and screenings, and emergency contact information. The health journal is designed to help individuals keep comprehensive records of their health to better discuss their medical history and care with healthcare providers.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 9

    Your Health Journal

    Keeping Track of Your Health

    Your Health Journal


    T HE B ASICS
    Name: Height: Weight: Date of birth: Primary doctor: Contact info: Specialist: Contact info: Specialist: Contact info: Specialist: Contact info: Specialist: Contact info: Pharmacy: Contact info: Health insurance: Policy number: Contact info: Vision insurance: Policy number: Contact info: Dental insurance: Policy number: Contact info: Social Security Number: Blood Type: Date of last physical exam: Medication allergies:

    Y OUR H EALTH N OW

    Existing Conditions
    Write down every SIGNIFICANT ailment or condition that you have RIGHT NOW. Ailment/Condition Current treatment or current med- Other info (name of ication youre taking for it (include specialist, surgery type name, dosage, and frequency) and date, etc.)

    Current Health
    Are any specific health conditions/symptoms bothering you? What are the symptoms? When did they start?

    Are you on a special or restricted diet?

    Are you under medical care? For what?

    Current Medications
    (Prescribed meds, herbal supplements, vitamins, over-the-counter drugseverything that you are taking on a regular basis for any reason at all) Name of medication Dosage and Date you frequency began taking it The reason youre taking it Prescribing physician (with contact info) Special instructions (e.g., take with liquid or food)

    Current Medical Symptoms


    Context and length of illness can often be important clues, and many patients dont think to really record when things start and how they feel. Date Description of symptoms (include timing, duration, location, intensity, and provoking events) Action

    Vital Statistics/Lab Numbers


    These numbers are an important part of understanding your overall health. Ask your doctor to help you keep track of them. Date Ht Wt Blood Heart HDL Pres Rate LDL Total Trig Chol Blood CRP Sugar HCT

    Ht, height; wt, weight; Blood Pres, blood pressure; HDL, high-density lipoprotein; LDL, low-density lipoprotein; Total Chol, total cholesterol; Trig, triglycerides; CRP, C-reactive protein; HCT, hematocrit.

    Y OUR H EALTH H ISTORY

    Immunizations
    Fill in date received and any followup needed.

    Tetanus, Diphtheria (td): Influenza (Flu shot): Hepatitis B: Hepatitis A: Measles, Mumps, Rubella: Meningococcus (Meningitis): Chicken Pox: Pneumonia (Pneumococcal): TB Screen: Other:

    Major Illnesses
    Date Illness Type Treatment

    Hospitalizations
    Date Reason Treatment

    Surgeries/Procedures
    Date Type Outcome

    Chronic Diseases
    Type When diagnosed Treatment Current treatment

    Allergies/reactions (e.g., medications, latex):

    Physical limitations (e.g., corrected vision, hearing aid, arthritis):

    Y OUR FAMILY H ISTORY

    Relevant Family Health History


    List the significant ailments and conditions experienced by family members and relatives, back to your grandparents, that your physician feels are a GENETIC CONCERN. Include your spouse, but the rest of the list should be blood relatives.

    Relative (how Condition or related to you) ailment

    Age (or date of How it was death and age treated attained)

    If deceased, did it cause or seriously contribute to death?

    K EEPING U P

    WITH

    Y OUR H EALTH

    Health Exams and Screenings


    Fill in the date that the test is performed and the results. Make several copies of the form so you can use it for several years. Date Urinalysis Eye exam Blood pressure Cholesterol Depression STDs Colon exam Skin exam Mammogram Pelvic exam Pap test Testicular exam Results

    I N C ASE

    OF

    E MERGENCY (ICE)

    Who should be called in case of an emergency? Do you have any legal documents or directives about your care?

    Main Contact
    Name: Relationship: Address: Home phone: Work phone: Cell phone:

    Secondary Contact
    Name: Relationship: Address: Home phone: Work phone: Cell phone:

    Organ Donor Yes ____ Living Will


    Location:

    No ____ No ____ Yes ____ No ____ No ____

    Yes ____

    Do-Not-Resuscitate Order
    Location:

    Health care Proxy


    Location: Contact:

    Yes ____

    Medical Power of Attorney


    Location: Contact:

    Yes ____

    No ____

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