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To manage my health and

Goal: When you experience any of the
medications, I agree to
following symptoms, here is what you should do:
Take this Personal Health
Symptom: What you should do:
Record with me to all doctor
visits and future hospitali-
zations and in the event of

Call my doctor if I have

questions about my medica-
tions or if I want to change
how I take my medications

Tell my doctors about ALL

medications I am taking,
If you experience any of the following symptoms,
including over-the-counter
call your doctor or go to the clinic IMMEDIATELY:
drugs, vitamins and herbal Name: _____________________
formulas. Symptom:
Update my Medication Rec-
ord with any changes to my
medications Important phone numbers:
Know why I am taking each PCP: _______________
of my medications Home Health: _______________
DME: _______________
Know how much, when and
for how long I am to take
each medication If you experience any of these symptoms, Emergency Contact Information:
CALL 911 !!!!!!! Name: _____________________
Know possible medication
Contact #: __________________
side effects to watch out for Symptom:
and what to do if I notice
any. Name of hospital
City, State

People for me to contact:

Contact Name:
Contact Phone Number:
Contact E-mail:
Personal Health Information Medicines I Take Recent Test Results
Date Date Weight Blood Pulse Blood
Time I Take Pressure Sugar
Personal Information: Medication Dose Medication
DOB: ____/____/____

Allergies: ______________________________________


Caregiver information:

Name: _______________________________________

Home Phone: _________________________________

Alternate Phone: ______________________________

Relationship: _________________________________

Advance Directives:

Advance Directives? YES NO

Do Not Resuscitate Comfort Care

Health Care Proxy/DPOA

Name of Proxy/DPOA: ____________________________

My Medical Conditions: Recent Hospitalizations

Arthritis Abnormal Heart Rhythym Admit Date: ____/____/____
Discharge Date: ____/____/____
Cancer Diabetes
Hospital: __________________________________
PVD Heart Disease
Reason: ___________________________________
Heart Failure High Blood Pressure
Immunizations __________________________________________
Hip Fracture/ Lung Disease Admit Date: ____/____/____
Replacement Immunization Date Received
Discharge Date: ____/____/____
Stroke Pacemaker
Flu Shot Hospital: __________________________________
Serial #: ________________
Other diagnoses: __________________________ Pneumonia Shot Reason: ___________________________________
_________________________________________ Tetanus __________________________________________