Free Patient Medical Statement Template
Patient Medical Statement
Patient Information
|
Full Name: |
Myron Burton |
|---|---|
|
Date of Birth: |
January 1, 2050 |
|
Patient ID: |
123456 |
|
Contact Information: |
Springfield, IL 62704 |
Medical History
-
Diabetes: Diagnosed in 2070
-
Hypertension: Diagnosed in 2075
-
Asthma: Diagnosed in childhood
-
Allergies: Penicillin
-
Surgeries:
-
Appendectomy: 2060
-
Knee Replacement: 2078
-
Current Medications
-
Metformin 500 mg: Twice daily
-
Lisinopril 10 mg: Once daily
-
Albuterol Inhaler: As needed
-
Levothyroxine 100 mcg: Once daily
Recent Vital Signs and Lab Results
|
Measurement |
Result |
Date |
|---|---|---|
|
Blood Pressure |
130/85 mm Hg |
September 20, 2083 |
|
Hemoglobin A1c |
7.2% |
August 15, 2083 |
|
Cholesterol |
Total: 180 mg/dL |
August 15, 2083 |
|
Weight |
180 lbs |
September 20, 2083 |
Physician's Notes
Mr. Myron Burton has shown stable responses to his medication regimen. Blood pressure and blood sugar levels are within acceptable ranges, though continued monitoring is advised. The patient reports occasional shortness of breath, which may be attributed to asthma. Regular follow-ups are strongly recommended.
Signature
[YOUR NAME], Physician
Date: 09/28/2083
