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My Medical History

Medical records

Download and print the "My Medical History Checklist" here!

 

                   My Medical History

 

                                         My Personal Information

Name:
Gender:
Date of Birth:
Current Address:
Phone Number:
Primary Lanugage:

 

                                   My Current Medical Conditions

Diagnosis Date of Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

                                      My Past Medical Conditions

 
 
 

 

    Medical Conditions in My Family (Mother, Father, Siblings)

Family Member Diagnosis

 

 

 

 

 

 

 

                                        My Current Medications

Name Dosage

 

 

 

 

 

 

 

 

 

                                           My Past Medications

Name Dates and Dosage Taken

 

 

 

 

 

 

 

 

 

                                                     My Allergies

 

 

 

 

 

 

 

                                           My Health Insurance

Name of Insurance Company Phone Number

 

 

 

 

 

                                                   My Doctors

Name and Speciality Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

                            My Emergency Contact Information

Name and Relationship Phone Number

 

 

 

 

 

 

 

 

 

 

 

                              Other Information about My Health

 

 

 

 

 

 

 

 

 

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PDF icon TOOLMedicalHistoryWorksheet.pdf33.44 KB