lifecenter

Personal Health Record - Create Your Own

Media Type

Info Sheet

Reviewed Date

Feb 26, 2018

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Creating a plan for successful caregiving includes organizing information to support daily care.

A personal health record is a tool that enables consumers to manage health information so they can communicate more effectively and easily with health care providers. Ideally, the PHR would include an up-to-date summary of doctor and hospital visits, medications, over-the-counter products, allergies, test results, and chronic diseases and conditions in one convenient and confidential location. This will save time and minimize stress, especially in emergency situations.

Personal health records detail information in a variety of areas:

  • Emergency contacts
  • Personal information
  • Insurance
  • List of doctors and other healthcare providers
  • Allergies, medications, immunizations, general health information
  • Preferred hospital
  • Advance directives and/or health care power of attorney forms

Personal health records can be maintained using electronic or paper format:

  • Index cards
  • Notebook or folder
  • Computer software
  • Flash drive or CD

A number of free and commercially available products are available for consumers to keep track of information.

The following example of a basic personal health record can be used to begin gathering information. Once the information is recorded, keep in mind that the effectiveness of the profile depends upon its being kept current. Update your profile each time a change occurs.

Key words: personal medical record, electronic health record, patient health record, personal health

References:
http://www.nlm.nih.gov/medlineplus/personalmedicalrecords.html
 

Name:_________________________________DATE REVISED:___________
Birthdate:_________________________Height ___________Weight:________
Vision: glasses contacts low vision other____________________________
Hearing Loss: hearing aids reads lips reads sign language
Swallowing difficulties: _____________________________________________
________________________________________________________________
Allergies:_________________________________________________________
________________________________________________________________
Advance Directives - copy located/attached: __________________
Health Care Power of Attorney- copy located/attached:__________
Immunization Record – copy located/attached: ________________

Lifestyle Risk Factors:

 

Alcohol Drink(s) Per Week: Number of Years:
Smoking Pack(s) Per Day: Number of Years:
Drug Use Frequency/Type: Number of Years:
Weight Body Mass Index: Normal Overweight Obese
Exercise Type(s) of Exercise: Days Per Week:
     
     

 

Emergency Contacts

 

Name  
Relation  
Street Address  
City, State, Zip  
Home or Work Phone  
Cell Phone  
E-mail  

 

Name  
Relation  
Street Address  
City, State, Zip  
Home or Work Phone  
Cell Phone  
E-mail  

 

 

Medical Emergency Contact Information

 

Hospital Preference  
Primary Insurance  
Secondary Insurance  
Primary Doctor/ Phone  

 

Other Healthcare Providers

 

Name/Specialty  
Phone  
Name/Specialty  
Phone  
Name/Specialty  
Phone  
Name/Specialty  
Phone  
Name/Specialty  
Phone  

 

Other Key Contacts – Family / Friends

 

Name  
Relation  
Street Address  
City, State, Zip  
Home or Work Phone  
Cell Phone  
E-mail  

 

Name  
Relation  
Street Address  
City, State, Zip  
Home or Work Phone  
Cell Phone  
E-mail  

 

 

Name  
Relation  
Street Address  
City, State, Zip  
Home or Work Phone  
Cell Phone  
E-mail  

 

 

Name  
Relation  
Street Address  
City, State, Zip  
Home or Work Phone  
Cell Phone  
E-mail  

 

Functional Information

Medical Diagnoses/condition/surgery:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Equipment and devices used: ______________________________________
________________________________________________________________
________________________________________________________________

Prosthetic / Orthotics Information

Device used  
Pros/Orthotist Name  
Street Address  
City, State, Zip  
Home or Work Phone  
Cell Phone  
E-mail  

Functional Status

Activity Can Do This Alone Need Someone to Stand By Needs Hands-on Help
In/out of Bed      
In/out of Chair      
Walking      
Stairs      
Bathing      
Dressing      
Using the Toilet      
Eating and Swallowing      
Housework      
Communication      
Safet      

Medication Information

Pharmacy Name  
Street Address  
City, State, Zip  
Phone  
E-mail  

 

Medication Dose / Frequency Reason for Taking
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

 

Reviewed November 2017

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This content is for informational purposes only. It does not replace the advice of a physician or other health care professional. Reliance on this site's content is solely at your own risk. Shirley Ryan AbilityLab disclaims any liability for injury or damages resulting from the use of any site content. © Shirley Ryan AbilityLab (formerly Rehabilitation Institute of Chicago). Henry B. Betts LIFE Center – (312) 238-5433 – https://www.sralab.org/lifecenter

Publication Information

Title

Personal Health Record – Create Your Own

Author

Henry B. Betts LIFE Center

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