Health Information Worksheet

Name	Date of Birth & Age	Insurance ID#

Medications: Get information directly off prescription bottle(s)
Name of medication (generic or brand name)	Strength of medication (e.g., 10mg)	How often you take medication & what you take it for

Ongoing Conditions
For example: depression, asthma, diabetes	When the condition was diagnosed (year)	Name of doctor treating the condition

Drug and Other Allergies
List any drug allergies you have, as well as allergies to animals, foods, latex etc.	You may also want to include any medications that you find difficult to tolerate. For example, ibuprofen upsets your stomach

Hospitalizations and Surgeries
Condition	When it occurred (year)	Hospital where it occurred

Family History
List any conditions as well as cause of death, if the family member is deceased.	Include: Mother, Father, Grandparents.

Doctors: Those you see now and those you've seen in the past; any doctor who has medical information about you
Doctor's Name & Type of Doctor (for example: primary care, psychiatrist, rheumatologist)	Address & phone number of doctor	How often you see this doctor (e.g., once a week) or if you no longer see this doctor

EXAMPLE:

Jane Doe - dob: 6/22/1970 (34 yo) - Empire BC/BS: 0000-0000-000

Current Medications

Flovent - 44 mcg strength - 2 puffs twice a day for asthma

Albuterol (generic)- 2 puffs every 4 - 6 hrs as needed (use maybe 3 times a month) for asthma

Celexa - 20 mg - one tablet every evening for depression

Ongoing Conditions

Asthma (mild to moderate) - see Dr. Smith

Allergies - cats and dust (take Benedryl as needed) - see Dr. Smith

Depression - see Dr. Brown and Dr. Simon

Drug & Other Allergies

No drug allergies; allergic to cats and dust.

Erythromycin upsets my stomach.

Surgeries/Hospitalizations

Tonsils out - 1975 - General Hospital in Thatplace NY

Depression - 2000 - Anytown Medical Center in Anytown MA

Family History

Mother: 57 years old, in good health

Maternal grandmother: 80(?) years old, diabetes

Maternal grandfather: died of heart attack at 62 years old

Father: 59 years old, high blood pressure

Paternal grandmother: 80s(?) years old, high blood pressure

Paternal grandfather: 80s(?) years old, depression

Doctors

Dr. Joe Smith, Primary Care Doctor, 123 Main St., Suite 1C, Anytown MA 12345, 203-555-5555. See as needed.

Dr. Ralph Brown, Psychiatrist, 76 W. 12th St., Anytown MA 12345, 203-555-0000. See once a month.

Dr. Susan Simon, Psychologist, 345 Sycamore Rd., Anytown MA 12345, 203-000-0000. See once a week.

Dr. Eileen Robertson, Gynecologist, 123 Main St., Suite 2B, Anytown MA 12345, 203-555-5050. See once a year or as needed.

Dr. Mark Parks, Primary Care Doctor (until 1998), 77 West End Ave., Suite 345, Thatplace NY 23456, 123-123-1234. No longer see; moved to MA.

Dr. Arnold Pike, Gynecologist (until 1998), 900 Tipton Blvd, Suite 23D, Thatplace NY 23456, 123-123-3456. No longer see; moved to MA.