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Rehabilitation Institute of Chicago: LIFE Center

Personal Health Record - Create Your Own

Reviewed August 2015
Author: Rehabilitation Institute of Chicago LIFE Center
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
http://www.medicare.gov/Publications/Pubs/pdf/11397.pdf
http://www.medicare.gov/phr/LearnMoreAboutPHR.asp

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
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     


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