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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