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COMPLIMENTARY PERSONAL HEALTH RECORD
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This form will serve as a dynamic document for patients to continually update and chart their ongoing and changing medical history. The following information is essential for a physician’s staff to provide care in a manner that is compatible with your general health.
This personal health record is provided to you for your convenience only. Entering information into this document does not guarantee that any physician will see it. This form should not be used as a substitute for directly communicating with your physician.
It is important that you provide accurate information so the physician may provide you safe and efficient treatment. Incorrect information can be dangerous to your health. If you have any questions regarding the following information, please consult your physician.
You can print and maintain a paper copy of your personal health record for your files and are strongly encouraged to do so each time you update this record. Neither The Memphis Medical Society, nor any physician affiliated with this organization assumes any liability whatsoever for your personal health record.
Section A: Patient Demographic Information
Title: _____ First Name: _________________________ Middle Name:__________________
(Mr., Ms., Mrs., Dr., etc.)
Last Name: ___________________________________ Suffix: _______________________(Jr., Sr., M.D., etc.)
SSN: ______-______-______ Date of Birth: ______ / ______ / ______(mm/dd/yyyy)
Martial Status: _____ Single _____ Married _____ Divorced _____ Widowed
Gender: _____ Male _____ Female
Street Address: ____________________________________________ Apt # _____________
City: ___________________________ State: _______________ Zip ______________
Contact Information :
Home Phone: (______) ______ - ______ Work Phone: (______) ______ - ______ ext: _____
Cell Phone: (______) ______ - ______ Email: ______________________________
Occupation: __________________________ Employer: ___________________________
Employer’s Address: ____________________________________________________________
Emergency Contact: __________________________________ Phone: _________________
Who referred you to our Practice ?- ______________________ May we contact them ? _______
Section B: Medical History
Your Doctors’ List (please, fill)
I don’t have a physician (please, circle if true)
Name of Physician: ________________ For care of: ____________ Phone number __________
Name of Physician: ________________ For care of: ____________ Phone number __________
Name of Physician: ________________ For care of: ____________ Phone number __________
Please list ALL the medications you are taking
(including any over-the-counter, vitamins, or herbal remedies):
Name: ______________________________ Dosage: ______________ How often: _________
Name: ______________________________ Dosage: ______________ How often: _________
Name: ______________________________ Dosage: ______________ How often: _________
Name: ______________________________ Dosage: ______________ How often: _________
Name: ______________________________ Dosage: ______________ How often: _________
Name: ______________________________ Dosage: ______________ How often: _________
Name: ______________________________ Dosage: ______________ How often: _________
Name: ______________________________ Dosage: ______________ How often: _________
Name: ______________________________ Dosage: ______________ How often: _________
Name: ______________________________ Dosage: ______________ How often: _________
The following is a list of the top twenty (20) medications currently in use in the United States. Please circle ALL of the following that you are taking:
Albuterol Alprazolam Amoxicillin Atenolol
Furosemide Hydrochlorothiazide Hydrocodone w/APAP Ibuprofen
Levoxyl Lipitor Lisinopril Norvasc
Premarin Prevacid Synthroid Toprol XL
Zithromax Zocor Zoloft Zyrtec
Have you ever had an allergic reaction to any medication? ______ Yes ______No
Please circle any of the following that you have had a drug allergy to
AND the nature of the reaction-
ACE inhibitors Anticonvulsants Aspirin
Beta blocker Cefaclor (Ceclor) Codeine / hydrocodone
Ibuprofen, Aleve Insulin IV contrast / Iodine
Multiple Antibiotic Sensitivity Penicillin
Sulfa drugs Other Medication(s) - ____________________________________________________
Have you had any serious illnesses or operations in the last five years? ______ Yes ______No
If yes, please describe and explain: _________________________________________________
______________________________________________________________________________
Have you ever had a blood transfusion? ____ Yes ____No If yes, list dates: ____________
Blood type: (circle one, if known) O+ A+ B+ AB+ O- A- B- AB-
Have you ever had a reaction to local anesthetic? ____ Yes ____ No If yes, please describe:____
WOMEN ONLY:
Are you pregnant? ______ Yes ______No ______ Maybe Nursing? ______ Yes ______No
Are you taking birth control pills? ______ Yes ______No
Please circle any of the following that you have been treated for:
AIDS Alzheimer’s Disease Anaphylaxis Anemia
Angina Artificial heart valves Artificial joints Allergies
Asthma Arthritis Back Problems Blood Disease
Cancer Circulatory problems Colitis Congenital heart lesions
Crohn’s Disease Diabetes Type I Diabetes Type 2 Emphysema
Epilepsy Food allergies Gastritis Glaucoma
Gout Headaches Heart murmur Hemophilia
Herpes Hepatitis (indicate type: _______) High blood pressure
HIV Kidney disease Liver disease Mitral valve prolapse
Mononucleosis Muscle Disorder Nervous problems Pace maker
Psychiatric care Radiation treatment Rheumatic fever Staff infections
Strep Throat Stroke Surgical implants (indicate type: ________)
Thyroid disease Tuberculosis Ulcer/colitis Venereal disease
WOMEN ONLY:
Abnormal PAP Breast mass or cyst Endometriosis Fibroids
Irregular periods Menopause Miscarriage Ovarian cysts
Postpartum depression Toxemia Tubal pregnancy
Section C: Personal Lifestyle Information
Do you smoke? ______ Yes ______No
Do you drink alcohol? ______ Yes ______No If yes, how many in an average week? ________
Do you use recreational drugs? ______ Yes ______No If yes, which ones? ________________
Do you have a history of domestic violence or sexual abuse? ______ Yes ______No
Do you exercise regularly? ______ Yes ______No
Is there anything else that you feel we should know? ___________________________________
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