Personal Medical History Form

Personal Medical History Form Section 1 is intended for use by everyone. It is important and a good idea to have this information available for when it is needed.

Copy and paste the Personal Medical History Form to a Word program. Then fill it out, print it and keep it in a secure place.

Personal Medical History Section 1

Personal Details

Name (prefix, first, last):

Date Of Birth (DOB):

Gender:

Ethnicity:

Marital Status:

Height:

Weight:

Contact Information

Next of Kin (NOK) or Friend:

Name:

Phone Number:

Address:

Medical Summary

1. Blood Type:

Blood transfusions can be the most critical part of a medical procedure. Blood transfusions play a lifesaving role in serious accidents of any type.

If you may ever need a blood transfusion, it is an essential requirement for the medical personnel treating you to know your blood type. If not available, you have to have stat tests which cause time delays and may take too long in order to save your life.

Blood transfusions help save nearly 10,000 lives each day. Therefore, if you don't know your blood type, get a blood test and identify your blood type at your earliest convenience. It is a quick and easy test.

Blood Types: A+ve, A-ve, B+ve, B-ve, AB+ve, AB-ve, O+ve, O-ve

2. Current Medical Conditions or Diagnosis

Personal Medical History Form List of Conditions / Diagnosis: Allergies, Arthritis, Bleeding tendencies, Blindness, Cancer, Congenital abnormalities, Dementia, Diabetes, Digestive disorder, Ear, nose or throat disorder, Epilepsy, Gastrointestinal disorder, Heart attack, Heart disease, High blood pressure, Infectious disease, Kidney disease, Liver disease, Lung disease, Neurological disease, OBGYN, Osteoporosis, Respiratory Disease, Seizures, Stroke, Thyroid Problems, Vascular Disease

1 Condition/Diagnosis:

Diagnosed by:

Date:

2 Condition/Diagnosis:

Diagnosed by:

Date:

3 Condition/Diagnosis:

Diagnosed by:

Date:

3. Current Medications

If medication is a narcotic, include contact information of the prescribing physician.

Personal Medical History Form Medications: Abilify, Accutane, Aciphex, Actos, Acyclovi, Adderall, Adderall XR, Advair, Albuterol, Aldactone, Allegra, Allopurino, Altace, Ambien, Amiodarone, Amoxicillin, Aricept, Atarax, Atenolol, Ativan, Atrovent, Augmentin, Avalide, Avandia, Avelox, Azithromycin, Baclofen, Bactrim, Bayer ASA, Benadryl, Benicar, Bentyl, Biaxin, Botox, Bupropion, Buspar, Cardura, Ceftin, Celebrex, Celexa, Chantix, Cialis, Cipro, Claritin, Clindamycin, Clonidine, Cogentin, Concerta, Coreg, Coumadin, Cozaar, Crestor, Cymbalta, Darvocet, Decadron, Demerol, Depakote, Desyrel, Diflucan, Dilantin, Dilaudid, Dioricet, Diovan, Diovan HCT, Dopamine, Doxycycline, Duragesic, Dyazide, Effexor, Elavil, Enebrel, Erythromycin, Flagyl, Flexeril, Flomax, Flonase, Fosamax, Geodon, Glipizide, Glucophage, Haldol, Heparin, Hydrocodone, Imitrex, Inderal, Indocin, Insulin, Keflex, Keppra, Klonopin, Lamictal, Lanoxin, Lasix, Levaquin, Lexapro, Lipitor, Lisinopril, Lodine, Lomotil, Lopressor, Lotrel, Lovenox, Lunesta, Lyrica, Macrobid, Meclizine, Medrol, Meridia, Methadone, Methotrexate, Mevacor, Mirapex, Mirena, Mobic, Morphine, Motrin, MS-Contin, Mucomyst, Naprosyn, Neurontin, Nexium, Niaspan, Noctec, Norvasc, NuvaRing, Omnicef, Ortho Tricyclen, Oxycodone, Oxycontin, Paxil, Penicillin, Pepcid, Percocet, Phenergan, Phentermine, Piroxicam, Plavix, Pravachol, Prednisone, Prevacid, Prilosec, Prometrium, Propoxyphene, Protonix, Provera, Provigil, Prozac, Pseudoephedrine, Pyridium, Reglan, Relafen, Remeron, Restoril, Retin-A, Risperdal, Ritalin, Robaxin, Seroquel, Sinemet, Singulair, Skelaxin, Soma, Speptra, Strattera, Suboxone, Synthroid, Tegretol, Terazosin, Tessalon, Topamax, Toprol, Toradol, Tricor, Trileptal, Tussionex, Tylenol, Tylenol-Codeine, Ultracet, Ultram, Valium, Valtrex, Vasotec, Verapamil, Viagra, Vicodin, Voltaren, Vytorin, Xanax, Xenical, Yasmin, Yaz, Zanaflex, Zantac, Zestoretic, Zetia, Zocor, Zoloft, Zyban, Zyprexa, Zyrtec

1 Current Medication:

Dosage:

Prescribed By:

2 Current Medication:

Dosage:

Prescribed By:

3 Current Medication:

Dosage:

Prescribed By:

4 Current Medication:

Dosage:

Prescribed By:

5 Current Medication:

Dosage:

Prescribed By:

4. Drug Allergies/Reactions

List all medications to which you have adverse reactions and the type of reaction. Example: rash, low blood pressure, shortness of breath, nausea, etc. Was the reaction threatening?

See list of medications above for reference.

Personal Medical History Form Allergic reactions: Abdominal pain, Congestion, Cramps, Diarrhea, Difficulty Breathing, Dizziness, Confusion, Itchiness, Itchy-red-watery eyes, Rash, Sneezing, Swelling in throat, Vomiting

1 Drug Allergy to:

Type of reaction:

Life Threatening: Yes No

2 Drug Allergy to:

Type of reaction:

Life Threatening: Yes No

3 Drug Allergy to:

Type of reaction:

Life Threatening: Yes No

5. Routine Allergies

Example: insect bites, animal fur, dust pollens, etc. Mild: itching, sneezing; Moderate: swelling; Severe: shortness of breath, low blood pressure

Allergic reactions: Abdominal pain, Congestion, Cramps, Diarrhea, Difficulty Breathing, Dizziness, Confusion, Itchiness, Itchy-red-watery eyes, Rash, Sneezing, Swelling in throat, Vomiting

1. Routine Allergy:

Reactions:

2. Routine Allergy:

Reactions:

3. Routine Allergy:

Reactions:

6. Immunization Information

Tetanus (booster)

Level:

Date:

Hepatitis A

Level:

Date:

Hepatitis B

Level:

Date:

7. Bleeding Disorders

Do you have a known or defined bleeding disorder?

Example: VonWillebrandt’s Disease, Hempphilia A, Hemophilia B

Yes:

No:

8. Current Physicians

1 Physicians Name:

Physician Specialty:

Phone Number:

Address (city, state):

2 Physicians Name:

Physician Specialty:

Phone Number:

Address (city, state):

3 Physicians Name:

Physician Specialty:

Phone Number:

Address (City, State)

9. Personal Medical History Form Disclaimer

Nothing contained in Answer My Health Question .net is intended to be instruction, medical diagnosis or treatment oriented. It is not to be relied on to suggest a course of treatment for a particular individual, nor should it be used in place of a visit, call, consultation or the advice of your physician or other qualified health care provider.

Answer My Health Question .net will not be liable for any personal injury, damage and/or liability arising out of your use of the Personal Medical History Form.

Please use the Contact Us page for any questions or comments you may have regarding the Personal Medical History Form page.

Return to My Medical History from Personal Medical History Form Tags: Personal Medical History Form, medical record management, medical record keeping