Free Health Record Template

Health Record

[YOUR COMPANY NAME] | [YOUR COMPANY ADDRESS]

I. Patient Information

  • Full Name: Duane Wiza

  • Date of Birth: 03/15/2059

  • Gender: Male

  • Address: Buffalo, NY 14201

  • Phone Number: 222 555 7777

  • Email Address: duane@you.mail

  • Emergency Contact:

    • Name: Emily Wiza

    • Relationship: Spouse

    • Phone Number: 222 555 7777

II. Health Insurance Information

  • Insurance Provider: NovaCare Health Solutions

  • Policy Number: NC-2089-00012345

  • Group Number: 67890

  • Coverage Details: Comprehensive Plan (includes routine, specialist, and emergency care)

III. Medical History

  • Chronic Conditions: Hypertension, Type 2 Diabetes

  • Allergies: Penicillin

  • Surgeries/Procedures:

    • Procedure Name: Appendectomy

    • Date: 07/2067

    • Hospital/Clinic: SynoVita Hospital

  • Medications:

    • Name: Metformin

    • Dosage: 500 mg

    • Frequency: Twice Daily

    • Name: Lisinopril

    • Dosage: 10 mg

    • Frequency: Once Daily

IV. Immunization Records

  • Vaccine Name: Influenza

    • Date Administered: 09/15/2088

    • Administrator: Dr. Susan Park, MetroHealth Clinic

  • Vaccine Name: COVID-28 Booster

    • Date Administered: 08/10/2088

    • Administrator: New York Public Health Center

V. Vital Signs (Most Recent)

  • Date of Measurement: 11/25/2089

  • Height: 6 ft 1 in (185 cm)

  • Weight: 200 lbs (90.7 kg)

  • Blood Pressure: 130/85 mmHg

  • Pulse Rate: 72 bpm

  • Temperature: 98.6°F (37°C)

VI. Clinical Notes

  • Primary Physician: Dr. [YOUR NAME]

  • Date of Last Visit: 11/25/2089

  • Summary of Findings: Patient presents stable vital signs with well-controlled diabetes and hypertension. Advised to maintain current medication regimen and increase physical activity.

VII. Laboratory/Diagnostic Tests

  • Test Name: HbA1c

    • Date: 11/15/2089

    • Results: 6.2% (within target range)

  • Test Name: Lipid Panel

    • Date: 11/15/2089

    • Results: Total Cholesterol: 180 mg/dL, LDL: 110 mg/dL, HDL: 50 mg/dL

VIII. Treatment Plan

  • Goals: Maintain HbA1c below 7%, blood pressure under 140/90 mmHg, and healthy weight.

  • Prescribed Interventions:

    • Continue current medications.

    • Incorporate 30 minutes of brisk walking five days a week.

    • Follow a low-sodium, balanced diet.

  • Follow-Up Schedule: Next appointment on 02/20/2090

IX. Patient Acknowledgment

I, Duane Wiza, confirm that the above information is accurate to the best of my knowledge.

Signature: _________________________
Date: 12/03/2089

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