Free Medical Record Template
Medical Record
Physician: [YOUR NAME], [YOUR COMPANY NAME]
The following information is a comprehensive medical record of the patient, intended for professional use only. This document ensure a detailed overview of the patient's medical history and current health status.
|
Patient Information |
Details |
|---|---|
|
Name: |
Ena Cassin |
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Date of Birth: |
2050-06-15 |
|
Gender: |
Female |
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Contact Number: |
222 555 7777 |
|
Email: |
ena@you.mail |
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Address: |
Louisville, KY 40201 |
Medical History
Ena Cassin has a history of hypertension, diagnosed in 2075, and has been under regular medication since. She also reports occasional migraines and has been treated for these symptoms with prescribed medication. There is no known history of major surgeries or hospitalizations in the past five years.
Allergies
The patient is allergic to penicillin and reports experiencing mild skin rashes upon exposure. There have been no life-threatening allergic reactions reported.
Current Medications
|
Medication |
Dosage |
Frequency |
|---|---|---|
|
Lisinopril |
10 mg |
Once daily |
|
Ibuprofen |
200 mg |
As needed |
Family Medical History
The patient's father has a history of cardiovascular disease, while her mother has been diagnosed with type 2 diabetes. Both conditions are being managed with routine medical interventions and lifestyle adjustments.
Recent Visits and Observations
During the last medical check-up dated April 15, 2083, Ena Cassin presented with stable vital signs. Blood pressure was recorded at 120/80 mmHg, and no new symptoms were reported. The physician recommended a follow-up appointment in six months to monitor hypertension management.
