PERSONAL

HEALTH
RECORD
NAME: DATE:

ADDRESS:

PHONE NUMBER: EMAIL:

Primary care provider:

Phone number:

Pharmacy:
Phone number:

Other providers:

Take this record with you to all doctor visits.

2017 Fidelis Care. Personal Health Record.

IMMUNIZATION PROVIDER VISITS
RECORD AND SURGICAL HISTORY

Childhood immunizations: List visits to all your providers:

Vaccine Doses Dates Date Provider Reason
DTaP

IPV

Hepatitis B

HiB

MMR

Varicella

PCV

Rotavirus

Influenza

Hepatitis A

HPV

Meningococcal

Other immunizations:
Vaccine Dates
Influenza

DTaP
Surgical history:
Pneumococcal
Date Surgery Reason
Varicella

Zoster

Other:

2017 Fidelis Care. Personal Health Record. H3328_FC 16023 2 2017 Fidelis Care. Personal Health Record. 3
MY HEALTH MEDICATION &
CONDITIONS SUPPLEMENT RECORD

1. Name: Date:
Warning signs:
Name Dose How Often? Reason New?
Action steps:

2.
Warning signs:
Action steps:

3.
Warning signs:
Action steps:

Special equipment and needs:

(For example, hearing aids, eyeglasses, cane, wheelchair, etc.)

Allergies:

2017 Fidelis Care. Personal Health Record. 4 2017 Fidelis Care. Personal Health Record. 5
QUESTIONS/ PERSONAL
GOALS INFORMATION

Questions for my primary care provider: Family caregiver information (if applicable)

Name:
Relation to patient:
Phone:
Alternate phone:
In what way does this caregiver help you manage
your conditions?

Questions for my providers: Name:

Relation to patient:
Phone:
Alternate phone:
In what way does this caregiver help you manage
your conditions?

I do not have a family caregiver.

Personal goals:
Advance directive/living will:
Yes No
Where can this be found?

2017 Fidelis Care. Personal Health Record. 6 2017 Fidelis Care. Personal Health Record. 7
NOTES

2017 Fidelis Care. Personal Health Record.