Recording a Health History: The Basics

General Information 

• This section should go at the beginning and should include:
• Name of patient, date of birth, address and phone numbers.
• Family doctor’s name and telephone number.
• Information on health insurance company, including member and group identification numbers, as well as address and phone number.
• Medicare and/or Medicaid number.
• Pharmacy name and telephone number.
• Emergency contact name and telephone number.
• Nearest hospital name and telephone number.
• Blood type.
• Allergies to drugs, foods, insects, etc.
• Special conditions, such as being diabetic, epileptic or having a pacemaker.
• Whether a living will or health care proxy exists.
  
  

Health Care Providers
List the names of all providers, their specialties, their telephone numbers and the conditions they’re treating. 

• Primary care physician/geriatrician.
• Eye doctor.
• Ear, nose and throat specialist.
• Dentist.
• Foot doctor.
• Heart specialist.
• Cancer specialist.
• Allergist.
• Orthopedist (specializes in bone, joint and muscle problems).
• Gastroenterologist (specializes in diseases of the digestive tract).
• Endocrinologist (specializes in diseases of the glands).
• Neurologist.
• Urologist (specializes in diseases of the urinary tract and male reproductive organs).
• Psychiatrist.
• Psychologist or social worker.
• Physical therapist.
• Nutritionist or dietitian.
• Visiting nurse.
• Home-care aide.
  

Medications
List all prescribed medications, the reason they were prescribed and the prescribing doctors. Include the start date and dosage. Any vitamins, herbs, supplements or over-the-counter medicines taken regularly should be included.

Download this personal medication record to help you track your loved one's medicines.