Fillable Adult Personal Health Record for Adults

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Adult Personal Health Record for Adults

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The Adult Personal Health Record for Adults form is 4 pages long and contains:

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  • 3 check-boxes
  • 393 other fields

Country of origin: US
File type: PDF

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:
I. IDENTIFICATION
Name (Last) (First) (Middle)
Maiden Name
Address
City State Zip Code Country
Home Phone
Cell Phone
Email Address
Date of Birth Male / Female
Height Weight Ethnicity
Blood Type
II. EMERGENCY CONTACTS
In Case of emergency, please contact:
Name (Last) (First)  (Middle)
Maiden Name
Address
City State Zip Code Country
Home Phone
Cell Phone
III. PHYSICIAN CONTACT
Name (Last) (First)
Phone
City State Zip Code Country
Personal Health Record
…for adults
IV. HEALTHCARE PROVIDERS
(a) Healthcare Provider Specialty
Name (Last) (First) (Middle)
Address
City State Zip Code Country
Phone
Emergency Phone (after hours)
(b) Healthcare Provider Specialty
Name (Last)  (First)  (Middle)
Address
City State Zip Code Country
Phone
Emergency Phone (after hours)
V. INSURANCE PROVIDERS
Insurance Provider Type
Company Name
Address
City State Zip Code Country
Identification/Group Number Member ID Number
Emergency Phone (after hours)
Reset Page
VI. LEGAL & MEDICAL DIRECTIVES
Living Will Durable Power of Attorney for Healthcare
Power of attorney Organ Donor YES
NO
_________________________________________________________
Document Location (safe, home, lawyer, etc.)
Location Name (Financial Institution)
Address
City State Zip Code Country
Contact Information
Home Phone
Cell Phone
Personal Health Record
…for adults
VIII. INFECTIOUS DISEASES
DISEASE AGE DATE
Chicken Pox
H1N1 Flu
Hepatitis
Measles
Mumps
Whooping Cough
Pneumonia
Polio
Rubella
Scarlet Fever
VII. Medical History
ILLNESS Date of Onset
Acquired Immunodeficiency Syndrome
(AIDS or HIV Positive
Arthritis
Asthma
Bronchitis
Cancer
Diabetes
High Blood pressure
Kidney Disease
Low Blood Pressure
Pain or Pressure in chest
Palpitations
Shortness of breath
Thyroid Problems
Urinary Tract Infection
IX. IMMUNIZATIONS
IMMUNIZATION AGE DATE
Diptheria
H1N1 Flu
Hepatitis B
Measles
Mumps
Whooping Cough
Polio
Rubella
Tetanus
Tuberculosis
Typhoid
Reset Page
X. ALLERGIES
ALLERGY REACTION
DATE OF LAST
OCCURENCE
Personal Health Record
…for adults
XII. LIFESTYLE
Alcohol Drink(s) per Week Number of years
Smoking Pack(s) per day Number of years
Exercise Type(s) of Exercise Days per Week
XIII. Health Log
DATE
DIAGNOSED
DOCTOR
NATURE OF
HEALTH
PROBLEM
AGE OF
ONSET
XI. FAMILY MEDICAL HISTORY
MOTHER FATHER
SIBLING
GRAND
PARENT CHILD
A
lcoholism
Arthritis
Asthma
Cancer
Diabetes
Heart
Condition
Hepatitis
High
Cholesterol
High
Blood
Pressure
Kidney
Disease
Smoking
Stroke
Reset Page
XIV. SURGERIES
(a) Date Doctor
Hospital
Su
rgical Procedure
Results
Comments
(b) Date Doctor
Hospital
Su
rgical Procedure
Results
Comments
(c) Date Doctor
Hospital
S
urgical Procedure
Results
Comments
Personal Health Record
…for adults
XV. HOSPITALIZATIONS
(a) Hospitalization Type
D
octor
H
ospital
Reason
Complications
(b)
Hospitalization Type
Doctor
H
ospital
Reason
Complications
(c)
Hospitalization Type
D
octor
H
ospital
Reason
Complications
Reset Page
Reset Form
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Adult Personal Health Record for Adults

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Completed 9 February 2020

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