Complete this form when youíre home without a lot of distractions. Then take it to the doctor with you. It will allow you to ask all the questions you have as well as being able to answer a lot of the questions the doctor might have for you. You need to use as many tools as possible that will allow you to speak for yourself wherever and whenever possible.

MEDICAL HISTORY for:
   Updated on:

Name

Address:

Phone:

Emergency Contact:

Primary Physician (Name, Address and Phone Number):

Secondary Physician (Name, Address and Phone Number):

Blood Type:

Allergies (Item to which you are allergic and the reaction that allergy causes):

Medications (Reason for use, Medication Name, Medication Instructions):

Family History (Type of medical condition, Persons relation to you):

Significant History (Date, Type of condition, How condition was treated, Condition Outcome):

Miscellaneous (Facts you feel your physician should be aware of):

Current Areas of Concern/Questions:

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Updated: 07/31/02