Simple Patient Health Record (PHR)

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Patient Information

• Full Name: Allene Tillman

• Date of Birth: 05/15/2050

• Gender: Female

• Contact Information:

  • Phone Number: 222 555 7777

  • Email Address: allene@you.mail

  • Address: Long Beach, CA 90801

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Emergency Contact Information

• Full Name: John Tillman

• Relationship to Patient: Spouse

• Phone Number: 222 555 7777

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Medical History

• Chronic Conditions: Hypertension, Type 2 Diabetes

• Allergies: Penicillin

• Past Surgeries:

  • Appendectomy, 07/12/2075 (No complications)

• Medications:

  • Lisinopril 10 mg, once daily

  • Metformin 500 mg, twice daily

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Immunization Record

• Vaccination Name: Influenza Vaccine

  • Date Administered: 09/01/2090

  • Additional Notes: Annual vaccine up-to-date

• Vaccination Name: COVID-19 Booster

  • Date Administered: 08/15/2090

  • Additional Notes: No side effects reported

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Recent Medical Visits

• Date of Visit: 10/25/2091

• Provider Name: Dr. Emily Smith / Springfield Medical Center

• Reason for Visit: Routine check-up

• Outcome/Follow-Up: Blood pressure within target range; continue current medications

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Additional Notes

• Date Added: 11/15/2091

• Details: Patient reports improved energy levels after starting yoga classes twice weekly

Prepared by: [YOUR NAME]
Date: 12/03/2061

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