[Full Name]

DOB:

Gender:

Height:

Weight:

Blood Type:

Appearance:

TABLE OF CONTENTS:

Today’s Appointment        1

ICE - Emergency Contacts        1

Relevant Physicians        1

Medications        1

Allergies/Adverse Reactions        1

Conditions        1

Hospitalizations & Surgeries        1

Medical History        2

Family History        2

Today’s Appointment

Ahead of an appointment, I like to make a copy of this document and fill out this section. That way, I have a record of prior appointments and can look back at changes to this document over time, and I am always working from the most recent and updated document.

• Questions for today’s visit

• List your questions, in priority order.

• One way to find your priorities is by ranking your symptoms or conditions in terms of worst to least manageable, and isolate the top 3.

• Details to share

• Any other information not listed below you want to make sure to share at this appointment?

• Notes from appt

• Take notes here. Consider bringing someone to appointment, or asking to record the appointment or have someone on the phone during appointment.

• Next Steps

• This is the to do list you create for after this appointment, pulled from your notes above.

ICE - Emergency Contacts

• List your emergency contacts here

Care Team

• List your treating physicians here. You can include all of your doctors, or just the ones pertinent to the appointment.

Preferred Pharmacy/Pharmacies

• Put your pharmacy here so you have the address and phone number.

Insurance(s) Details

• If you have insurance, it may be more convenient for you to put the details here than simply carrying the card.

Medications

• Include all medications here, with full name and dosage. Can also include when you began medication, as well as meds you have tried/failed with those dates.

Allergies/Adverse Reactions

• List all allergies and adverse reactions

Diagnoses & Conditions 

• Put every diagnosis and condition here. May be easiest for it to be as brief as possible, with further explanation below under Medical History.

Hospitalizations & Surgeries

• Hospitalizations, surgeries, procedures, etc. with dates.

Medical History 

• Full medical history, as far back as you can remember, with dates inasmuch as you can recall.

Family History

List all health conditions your family members experience(d) here. Include their ages, current health, and date and cause of deaths where applicable.

• Mother:
• Father:
• Siblings:
• Paternal Grandfather:
• Paternal Grandmother:
• Maternal Grandfather:
• Maternal Grandmother:
• Maternal Uncles & Aunts:
• Paternal Cousins:
• Maternal Cousins: