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My Medical History

Medical records

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


                   My Medical History


                                         My Personal Information

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










PDF icon TOOLMedicalHistoryWorksheet.pdf33.44 KB