Health Information Form for Adults
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- Chastity Townsend
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1 A. IDENTIFICATION B. EMERGENCY CONTACTS Name (Last) (First) (Middle) Maiden Name Primary Alternate In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Relationship Home Work Home Work Cell Cell of Birth Male Female In Case of Emergency, Notify: Secondary Contact Name (Last) (First) (Middle) Height Weight Eye Color Hair Color Relationship Ethnicity/Race Birthmarks/Scars Blood /RH Type Special Conditions Marital Status Occupation Company Name Home Cell Work In Case of Emergency, Notify: Medical Contact Number Languages Spoken Primary and Secondary Physician (Indicate Specialty) Primary Health Insurance Carrier Policy Number Secondary Health Insurance Carrier Policy Number Dentist Pharmacy
2 C. HEALTHCARE PROVIDERS Healthcare Provider Type Primary Care Physician Yes No Emergency No. (after hours) Name Group or Association Web /URL Healthcare Provider Type Primary Care Physician Yes No Emergency No. (after hours) Name Group or Association Web /URL Healthcare Provider Type Primary Care Physician Yes No Emergency No. (after hours) Name Group or Association Web /URL Healthcare Provider Type Primary Care Physician Yes No Emergency No. (after hours) Name Group or Association Web /URL
3 D. INSURANCE PROVIDERS Insurance Provider Type Company Name Web /URL Primary Insured Person Name Social Security No. Employer Name Contact Name Identification Group Number Member (ID) Number Contact Information Emergency No. (after hours) Number Insurance Provider Type Company Name Web /URL Primary Insured Person Name Social Security No. Employer Name Contact Name Identification Group Number Member (ID) Number Contact Information Emergency No. (after hours) Number Insurance Provider Type Company Name Web /URL Primary Insured Person Name Social Security No. Employer Name Contact Name Identification Group Number Member (ID) Number Contact Information Emergency No. (after hours) Number
4 E. LEGAL DOCUMENTS/MEDICAL DIRECTIVES Living Will Durable Power of Attorney for Healthcare Power of Attorney Document Location (Physical Location) Location Name (for example, Bank of America) Contact (Name of person who has access to the document) Contact Information Legal Representative (Name of person who you have assigned legal authority) Contact Information Home Pager Work Cell Work Home Cell Filed Pager Work Work Organ Donation Organ Donor Yes No State Where Registered Living Will Durable Power of Attorney for Healthcare Power of Attorney Document Location (Physical Location) Location Name (for example, Bank of America) Contact (Name of person who has access to the document) Contact Information Legal Representative (Name of person who you have assigned legal authority) Contact Information Home Pager Work Cell Work Home Cell Filed Pager Work Work Organ Donation Organ Donor Yes No State Where Registered
5 F. MEDICAL HISTORY check appropriate items Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive: Arthritis Asthma Bronchitis Cancer Chlamydia Diabetes Dizziness Emphysema Epilepsy Eye Problem Fainting Frequent or Severe Headache Glaucoma Gonorrhea Hearing Impairment Heart Condition Hemodialysis Herpes High Blood Cholesterol of Onset High Blood Pressure Hypoglycemia Jaundice Kidney Disease Low Blood Pressure Mental Retardation Pain or Pressure in Chest Palpitations Periods of Unconsciousness Rheumatic Fever Rheumatism Seizures Shortness of Breath Stomach, Liver, or Intestinal Problems Syphilis Tuberculosis Tumor Thyroid Problems Urinary Tract Infection Other of Onset G. INFECTIOUS DISEASES Disease Age Remarks Chicken Pox Hepatitis Measles Mumps Pertussis / Whooping Cough Pneumonia Polio Rubella Scarlet Fever Other
6 H.IMMUNIZATIONS BOOSTER 1 BOOSTER 2 BOOSTER 3 Immunization for Age Age Age Age Diphtheria Hepatitis B Measles Mumps Pertussis/Whooping Cough Polio Rubella Smallpox Tetanus Tuberculosis Typhoid Other I. ALLERGIES/DRUG SENSITIVITIES Allergy/Sensitivity Type (include medications, Reaction Last Occurred Treatment foods, environmental, or other)
7 J. FAMILY MEMBER HISTORY Mother Father Sibling(s) Grandparent(s) Children Enter ages of relatives If deceased, indicate age and cause of death Check all items that apply for their present state of health or any illnesses they have had. Alcoholism Arthritis Asthma Cancer Diabetes Emphysema Glaucoma Heart Condition Hemodialysis Hepatitis High Blood Cholesterol High Blood Pressure Kidney Disease Mental Retardation Rheumatic Fever Seizures Smoking Stomach, Liver, or Intestinal Problems Stroke Thyroid Disorders Tuberculosis Tumor Other
8 K. LIFESTYLE Alcohol Drink(s) Per Week Number of Years Smoking Pack(s) Per Day Number of Years Exercise Type(s) of Exercise Days Per Week L. HEALTH LOG Noninfectious major illnesses. Include pregnancies and childbirth. Diagnosed Nature of Health Problem Age at Onset Condition Status Remarks (Such as, medications, special tests, x-rays, length of hospital stay, surgery, and so on)
9 M. MEDICATIONS (Prescription/Nonprescription) Update Regularly Note: Include all prescription medications, over-the-counter medications (taken on a regular basis), vitamin supplements, and herbal remedies. Current Prescriptions: Name/Dose/Frequency Started Quantity Stop Prescribed By Prescription Prescription Allergic Reaction Comments Number Number
10 N. DOCTOR VISITS Diagnosis
11 O. HOSPITALIZATIONS ization Type (includes emergency room visits) Diagnosis Admission Discharge Complications ization Type (includes emergency room visits) Diagnosis Admission Discharge Complications ization Type (includes emergency room visits) Diagnosis Admission Discharge Complications
12 P. SURGERIES Results Procedure Description Comments Results Procedure Description Comments Results Procedure Description Comments Results Procedure Description Comments
13 Q. LAB OR IMAGING (Examples: X-ray, MRI, Mammogram) Test Type Test Type Requesting Administered by Requesting Administered by Result Result Test Type Test Type Requesting Administered by Requesting Administered by Result Result R. MEDICAL DEVICES (Examples: pacemaker, insulin pumps, breathing devices) Device Type Device Type
14 S. PHYSICAL/OCCUPATIONAL THERAPY Therapy Type Start Stop Frequency Therapist
15 T. VISION of Visit Physician of Visit Physician Vision RX Vision RX of Visit Physician of Visit Physician Vision RX Vision RX of Visit Physician of Visit Physician Vision RX Vision RX U. DENTAL of Visit Dentist Problems Resolution
Health Information Form for Adults
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