PERSONAL

HEALTH

RECORD

Take this record with you to all doctor visits.

NAME: DATE:

**** ******* ****. ******** ****** Record.

Primary care provider:

Phone number:

Pharmacy:

Phone number:

Other providers:

ADDRESS:

PHONE NUMBER: EMAIL:

IMMUNIZATION

RECORD

PROVIDER VISITS

AND SURGICAL HISTORY

List visits to all your providers:

Date Provider Reason

2017 Fidelis Care. Personal Health Record. H3328_FC 160**-*-**** Fidelis Care. Personal Health Record. 3 Childhood immunizations:

Vaccine Doses Dates

DTaP

IPV

Hepatitis B

HiB

MMR

Varicella

PCV

Rotavirus

Influenza

Hepatitis A

HPV

Meningococcal

Other immunizations:

Vaccine Dates

Influenza

DTaP

Pneumococcal

Varicella

Zoster

Other:

Date Surgery Reason

Surgical history:

Name: Date:

MY HEALTH

CONDITIONS

MEDICATION &

SUPPLEMENT RECORD

1.

Warning signs:

Action steps:

2.

Warning signs:

Action steps:

3.

Warning signs:

Action steps:

2017 Fidelis Care. Personal Health Record. 4

Name Dose How Often? Reason New?

2017 Fidelis Care. Personal Health Record. 5

Special equipment and needs:

(For example, hearing aids, eyeglasses, cane, wheelchair, etc.) Allergies:

2017 Fidelis Care. Personal Health Record. 6 2017 Fidelis Care. Personal Health Record. 7 QUESTIONS/

GOALS

Questions for my primary care provider:

Questions for my providers:

Personal goals:

Name:

Relation to patient:

Phone:

Alternate phone:

In what way does this caregiver help you manage

your conditions?

Name:

Relation to patient:

Phone:

Alternate phone:

In what way does this caregiver help you manage

your conditions?

Advance directive/living will:

Where can this be found?

PERSONAL

INFORMATION

Family caregiver information (if applicable)

Yes No

I do not have a family caregiver.

2017 Fidelis Care. Personal Health Record.

NOTES

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