Personal Medical History Form

 We've previously addressed the importance of maintaining a personal medical history at home.  Ideally, you have copies of records from your physician's office.  But if not, here's a form to get you started.  Do this now while your mind is clear.  It's a lot harder to remember critical information in a crisis.  (I tested this form.  It comes up beautifully on the blog as of this moment, and it can be copied and pasted into a Word document for printing.)  (ETA:  We now have a downloadable PDF)

PERSONAL MEDICAL HISTORY

Keep with your medical records and update regularly.

BLOOD TYPE

DATE LAST UPDATED

1. IDENTIFICATION & EMERGENCY INFORMATION

Full name	Date of birth	Phone
Emergency contact / relationship	Phone	Primary doctor / clinic

2. NORMAL-FOR-YOU FINDINGS

Record findings that are normal for you but might otherwise look abnormal to a caregiver.

3. VACCINATIONS

Record vaccine, date, dose/series if known, and reactions.

Vaccine / immunization	Date(s)	Dose / series	Reaction / notes

4. FAMILY HEALTH HISTORY

For blood relatives, record major illnesses and conditions, age at diagnosis when known, and age/cause of death.

Relative	Illnesses / conditions	Age at diagnosis	Age at death / cause

5. ILLNESSES, INJURIES & HOSPITALIZATIONS

Include dates, diagnosis/reason, treatment or medications, duration, complications, and outcome. Record falls and apparently minor events too.

Date	Illness / injury / reason	Treatment / medications	Duration / outcome

6. SURGERIES & PROCEDURES

Date	Surgery / procedure	Reason	Hospital / surgeon / notes
Date	Surgery / procedure	Reason	Hospital / surgeon / notes

7. REPRODUCTIVE HISTORY (if applicable)

Pregnancies	Children / number living	Miscarriages	Abortions / other notes

MEDICATIONS & LIFESTYLE

8. ALLERGIES & ADVERSE REACTIONS

List medication, food, environmental, and other allergies. Describe the reaction.

Allergen	Reaction	Severity / notes

9. CURRENT & PAST MEDICATIONS

Include every prescription and OTC medication. Note dose, frequency, reason, dates, and significant reactions.

Medication	Dose / frequency	Current?	Reason / response / notes

10. SUPPLEMENTS, HERBS & OTHER REMEDIES

Record amounts/frequency and purpose. Note whether herbs or remedies are harvested or prepared yourself.

Supplement / herb / remedy	Amount & frequency	Purpose	Self-harvested / prepared?

11. TOBACCO, ALCOHOL, CAFFEINE & OTHER DRUGS

Document current and past use, approximate amount/frequency, and when use stopped if applicable.

Tobacco / nicotine	Alcohol	Coffee / caffeine
Tea	Other / recreational drugs	Past use / quit dates

12. DIET & RECENT DIETARY CHANGES

Record important dietary patterns and changes, especially rapid changes such as a move to whole grains/high fiber, fasting, elimination diets, or other major changes.

13. ONGOING SYMPTOMS, FALLS & INJURIES

Continue recording events as they occur—even events that seem insignificant. Include date, symptoms/findings, treatment, and outcome.

Date	What happened / symptoms / findings	Treatment / medications	Outcome / follow-up

14. OTHER IMPORTANT INFORMATION FOR CAREGIVERS

Include chronic conditions, baseline measurements, implanted devices, special care needs, unusual reactions, previous diagnostic findings, or anything else a caregiver should know.

15. ADDITIONAL NOTES

RECORD-KEEPING REMINDER

Keep this form and supporting medical records in a heavy-duty waterproof bag. Bring them to medical visits. Keep blank paper with the records for additional notes. Update this record whenever important medical information changes.

Additional pages may be attached. This form organizes information; it does not replace professional medical records or medical advice.