Free Health Info Sheet Template
Health Info Sheet
Introduction
This Health Info Sheet is designed to provide a comprehensive overview of essential health information for use during medical appointments. It aims to streamline communication between patients and healthcare providers by consolidating important medical details into a single, easy-to-reference document.
Patient Information
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Name: [YOUR NAME]
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Date of Birth: April 15, 2050
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Address: 456 Oak Avenue, Rivertown, TX, 75001
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Phone Number: (555) 678-1234
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Email: [YOUR EMAIL]
Emergency Contacts
|
Name |
Relationship |
Phone Number |
|
|---|---|---|---|
|
Taylor Adams |
Spouse |
222 555 7777 |
taylor@email.com |
|
Riley Carter |
Parent |
222 555 7777 |
riley@email.com |
|
Morgan Green |
Sibling |
222 555 7777 |
morgan@email.com |
|
Casey Johnson |
Friend |
222 555 7777 |
casey@email.com |
Medical History
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Primary Care Physician: Dr. Ava Wilson
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Medical Conditions: Hypertension, Type 2 Diabetes, Asthma
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Surgeries:
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Appendectomy (June 10, 2050)
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Knee Replacement (January 25, 2053)
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-
Hospitalizations:
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Rivertown Medical Center (March 1, 2051 - March 5, 2051)
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Medications
|
Medication Name |
Dosage |
Frequency |
Start Date |
|---|---|---|---|
|
Metformin |
500 mg |
Twice daily |
May 1, 2050 |
|
Lisinopril |
10 mg |
Once daily |
June 15, 2050 |
|
Albuterol |
90 mcg |
As needed |
July 22, 2050 |
|
Aspirin |
81 mg |
Once daily |
August 30, 2050 |
Allergies
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Penicillin: Severe rash
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Peanuts: Mild gastrointestinal symptoms
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Shellfish: Hives
Immunizations
|
Vaccine |
Date Administered |
Next Due Date |
Provider |
|---|---|---|---|
|
Flu Vaccine |
October 10, 2050 |
October 10, 2051 |
Dr. Ava Wilson |
|
Tetanus |
November 15, 2050 |
November 15, 2055 |
Dr. Ava Wilson |
|
COVID-19 Booster |
December 5, 2050 |
December 5, 2051 |
Dr. Ava Wilson |
|
Pneumonia |
January 12, 2051 |
January 12, 2056 |
Dr. Ava Wilson |
Additional Notes
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Special Considerations: Requires frequent blood sugar monitoring.
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Recent Lab Results: Blood pressure within normal range, A1C level at 7.2%.
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Lifestyle Factors: Regular exercise routine, follows a low-sodium diet.
For any updates or changes to this information, please contact [YOUR NAME] at [YOUR EMAIL].
