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Personal Health Record
   
 

Here's what our clients are saying...

“Dad fell down the front step and broke his leg. Because all of his information was in one place, the admission process went smoothly.”

Privacy statement: We do not retain any of this information nor do we store it.

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Personal Health Record
 
Lifesaving Information for Emergencies
Fill out this form, print it, and store it in a prominent place (such as on your refrigerator) so emergency personnel can easily locate it in an emergency.  You may also want to print a copy to carry with you in your purse or wallet.  And, of course, be sure to keep your information up-to-date.

Personal Information

Full Name:  
Address:  
   
City, State, ZIP:   , 
Phone:  
     
Birth Date:  
Sex:   Male     Female
Social Security #:  
Private Insurance:  
Medicare #:  
Medicaid #:  
Family Physician:  
Physician Phone:  
Specialist:  
Specialist Phone:  
Hospital Preference:  


Medical History

Heart Condition:   Yes          No
Pacemaker:   Yes          No
High Blood Pressure:   Yes          No
Normal Reading for person:  
BP:  
Date:  
Diabetes:   Yes          No
    If Yes, please specify:
    Type:
    Amount
    Time
    Pills
    Dose
    Diet
Glasses:   Yes          No
Emphysema:   Yes          No
Epilepsy:   Yes          No
Asthma:   Yes          No
Cancer:   Yes          No
Parkinson's:   Yes          No
Contacts:   Yes          No
Dentures:   Yes          No
Arthritis:   Yes          No
Thyroid:   Yes          No
Memory Problem:   Yes          No
Hearing Impairment:   Yes          No
Other:  
Date of last tetanus shot:  


Medications & Instructions:

Where I keep my medications:

Allergies:

Special Health Problems:

Name of other people in household:

In case of emergency, contact:

Name:  
Address:  
   
City, State, ZIP:   ,
Phone:  
     
Do you have a living will?   Yes        No
Do you have a durable Power of Attorney for Health Care?  
Yes        No

If so, who has this information?
Name:  
Address:  
   
City, State, ZIP:   ,
     
Preferred Skilled
Nursing Facility:		  
Preferred Hospital:  
Preferred Home Care Agency:  


 

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