PHR-English-Adult

Health Information Form-for Adults

A. Identification B. Emergency Contacts

Name (Last) (First) (Middle)In Case of Emergency, Notify: Primary Contact Name (last) (First) (Middle)

Maiden Name

Primary AddressRelationship

CityStateZipCountryAddress

Alternate AddressCityStateZip CodeCountry

CityStateZip CodeCountryHome Phone Work Phone

Home PhoneWork PhoneCell PhoneEmail Address

Cell PhoneEmail Address

Date of BirthSex:

FORMCHECKBOX Male FORMCHECKBOX FemaleIn Case of Emergency, Notify: Secondary Contact

HeightWeightEye ColorHair ColorName (last)Name (middle)Name (first)

RaceBirthmark/ScarsRelationship

Blood/RH TypeSpecial ConditionsMarital StatusAddress

OccupationCityStateZip CodeCountry

Company NameHome PhoneWork Phone

CityStateZip CodeCountryCell PhoneEmail Address

Phone NumberLanguages SpokenIn Case of Emergency, Notify: Medical Contact

Primary Health Insurance Carrier

Secondary Health Insurance CarrierPolicy Number

Policy NumberDoctor (Indicate Specialty)

Phone Number

Dentist

Telephone Number

Pharmacy

Telephone Number

C. Healthcare Provider

Healthcare Provider SpecialtyPrimary Care Physician

FORMCHECKBOX Yes FORMCHECKBOX NoPhoneEmergency Phone No.(after hours)

NameEmail Address

Group or AssociationFax

AddressWeb Address/URL

CityStateZip CodeCountry

Healthcare Provider SpecialtyPrimary Care Physician

FORMCHECKBOX Yes FORMCHECKBOX NoPhoneEmergency Phone No.(after hours)

NameEmail Address

Group or AssociationFax

AddressWeb Address/URL

CityStateZip CodeCountry

Healthcare Provider SpecialtyPrimary Care Physician

FORMCHECKBOX Yes FORMCHECKBOX NoPhoneEmergency Phone No.(after hours)

NameEmail Address

Group or AssociationFax

AddressWeb Address/URL

CityStateZip CodeCountry

Healthcare Provider SpecialtyPrimary Care Physician

FORMCHECKBOX Yes FORMCHECKBOX NoPhoneEmergency Phone No.(after hours)

NameEmail Address

Group or AssociationFax

AddressWeb Address/URL

CityStateZip CodeCountry

D. Insurance Providers

Insurance Provider TypeE-mail AddressFax

Company NameWeb Address/ URL

AddressPrimary Insured Person-NameSocial Security No.

City StateZip CodeCountryName of Employer

Contact NamePhoneAddress

Identification-Group NumberMember(ID) NumberCity StateZip CodeCountry

Contact Information-PhoneEmergency Phone No.(after hours)Phone Number

Insurance Provider TypeE-mail AddressFax

Company NameWeb Address/ URL

AddressPrimary Insured Person-NameSocial Security No.

City StateZip CodeCountryName of Employer

Contact-NamePhoneAddress

Identification-Group NumberMember(ID) NumberCity StateZip CodeCountry

Contact Information-PhoneEmergency Phone No.(after hours)Phone Number

Insurance Provider TypeE-mail AddressFax

Company NameWeb Address/ URL

AddressPrimary Insured Person-NameSocial Security No.

City StateZip CodeCountryName of Employer

Contact-NamePhoneAddress

Identification-Group NumberMember(ID) NumberCity StateZip CodeCountry

Contact Information-PhoneEmergency Phone No.(after hours)Phone Number

E. Legal Documents/Medical Directives

FORMCHECKBOX Living Will FORMCHECKBOX Durable Power of Attorney for Healthcare

FORMCHECKBOX Power of Attorney Fax

Document Location (Physical Location)Contact (Name of person who has access to the document)

Location Name (for example Bank of America)Address

AddressCity StateZip CodeCountry

City StateZip CodeCountryContact Information

Legal Representative (Name of person who you have assigned legal authority)

Home PhoneCellular Phone

AddressPagerE-mail Address

City StateZip CodeCountryWork PhoneWork E-mail Address

Contact InformationFax

Home PhoneCellular PhoneDate Filed

PagerE-mail AddressOrgan Donation:

Work E-mail AddressWork PhoneOrgan Donor

FORMCHECKBOX Yes FORMCHECKBOX No State Where Registered

FORMCHECKBOX Living Will FORMCHECKBOX Durable Power of Attorney for Healthcare

FORMCHECKBOX Power of AttorneyFax

Document Location(Physical Location)Contact ( Name of person who has access to the document)

Location Name (for example Bank of America)Address

AddressCity StateZip CodeCountry

City StateZip CodeCountryContact Information

Legal Representative (Name of person who you have assigned legal authority)

Home PhoneCellular Phone

AddressPagerE-mail Address

City StateZip CodeCountryWork PhoneWork E-mail Address

Contact InformationFax

Home PhoneCellular PhoneDate Filed

PagerE-mail AddressOrgan Donation:

Work E-mail AddressWork Phone Organ Donor

FORMCHECKBOX Yes FORMCHECKBOX No State Where Registered

F. Medical History(Check appropriate)

FORMCHECKBOX Acquired Immunodeficiency Sndrome(AIDS) or HIV Positive:Date of Onset FORMCHECKBOX High Blood PressureDate of Onset

FORMCHECKBOX

Arthritis FORMCHECKBOX

Hypoglycemia

FORMCHECKBOX

Asthma FORMCHECKBOX

Jaundice

FORMCHECKBOX

Bronchitis FORMCHECKBOX

Kidney Disease

FORMCHECKBOX

Cancer FORMCHECKBOX

Low Blood Pressure

FORMCHECKBOX

Chlamydia FORMCHECKBOX

Mental Retardation

FORMCHECKBOX

Diabetes FORMCHECKBOX

Pain or Pressure in Chest

FORMCHECKBOX

Dizziness FORMCHECKBOX

Palpitations

FORMCHECKBOX

Emphysema FORMCHECKBOX

Periods of unconsciousness

FORMCHECKBOX

Epilepsy FORMCHECKBOX

Rheumatic Fever

FORMCHECKBOX

Eye Problem FORMCHECKBOX

Rheumatism

FORMCHECKBOX

Fainting FORMCHECKBOX

Seizures

FORMCHECKBOX

Frequent or Severe Headaches FORMCHECKBOX

Shortness of Breath

FORMCHECKBOX

Glaucoma FORMCHECKBOX

Stomach Liver or Intestinal Problems

FORMCHECKBOX

Gonorrhea FORMCHECKBOX

Syphilis

FORMCHECKBOX

Hearing Impairment FORMCHECKBOX

Tuberculosis

FORMCHECKBOX

Heart Condition FORMCHECKBOX

Tumor

FORMCHECKBOX

Hemodialysis FORMCHECKBOX

Thyroid Problems

FORMCHECKBOX

Herpes FORMCHECKBOX

Urinary Tract Infection

FORMCHECKBOX

High Blood Cholesterol FORMCHECKBOX

Other

G. Infectious Diseases

Disease

AgeDateRemarks

Chicken Pox

Hepatitis

Measles

Mumps

Pertussis /Whooping Cough

Pneumona

Polio

Rubella

Scarlet Fever

Other

H. ImmunizationsBooster 1Booster 2Booster 3

Immunization forAgeDateAgeDateAgeDate

Diptheria

Hepatitis B

Measles

Mumps

Pertussis/Whooping Cough

Polio

Rubella

Smallpox

Tetanus

Tuberculosis

Typhoid

Other

I. Allergies/Drug Sensitivities

Allergy/Sensitivity Type (include medications foods environmental or other)ReactionDate last Occurred Treatment

J. Family Member History

MotherFatherSibling(s)

Grandparent(s)

Children

Enter ages of relatives

If deceased, indicate age and cause of death

Check all items that apply for their present state of health or any illnesses they have had

Alcoholism

Arthritis

Asthma

Cancer

Diabetes

Emphysema

Glaucoma

Heart Condition

Hemodialysis

Hepatitis

High Blood Cholestrol

High Blood Pressure

Kidney Disease

Mental Retardation

Rheumatic Fever

Seizures

Smoking

Stomach Liver or Intestinal Problems

Stroke

Thyroid Disorders

Tuberculosis

Tumor

Other

K. Lifestyle

FORMCHECKBOX AlcoholDrink(s) Per WeekNumber of Years

FORMCHECKBOX SmokingPack(s) Per DayNumber of Years

FORMCHECKBOX ExerciseType(s) of Exercise

Days Per Week

L. Health Log (Noninfectious major illnesses. Include pregnancies and childbirth)

Date DiagnosedDoctorNature of Health ProblemsAge at OnsetCondition StatusRemarks (Such as, medications, special tests, x-rays, length of hospital stay, surgery and so on)

M. MedicationsNote: Include all prescription medications, (such as nitroglycerin) over-the-counter medications (taken on a regular basis), vitamin supplements, and herbal remedies

DateMedication / DosageFrequency

N. Doctor Visits

DateDoctorReasonDiagnosis

O. Hospitalizations

Hospitalization Type (includes emergency room visits)Diagnosis

Admission DateDischarge Date

Doctor

Hospital

ReasonComplications

Hospitalization Type (includes emergency room visits)Diagnosis

Admission DateAdmission Date

Doctor

Hospital

ReasonComplications

Hospitalization Type (includes emergency room visits)Diagnosis

Admission DateDischarge Date

Admission Date

Doctor

Hospital

ReasonComplications

P. Surgeries

DateDoctorResults

Hospital

Surgical Procedure

DescriptionComments

DateDoctorResults

Hospital

Surgical Procedure

DescriptionComments

DateDoctorResults

Hospital

Surgical Procedure

DescriptionComments

Q. Lab or Imaging (Examples: X-ray, MRI, Mammogram)

Test TypeDateTest TypeDate

Requesting DoctorAdministered byRequesting DoctorAdministered by

ReasonReason

ResultResult

Test TypeDateTest TypeDate

Requesting DoctorAdministered byRequesting DoctorAdministered by

ReasonReason

ResultResult

R. Medical Devices (Examples: pacemaker, insulin pumas, breathing devices)

Device TypeDoctorDevice TypeDoctor

HospitalDateHospitalDate

ReasonReason

S.Physical/Occupation Therapy

Therapy TypeStart DateStop DateFrequencyTherapist

T. VISION

Date of VisitPhysicianDate of VisitPhysician

Vision RXVision RX

Date of VisitPhysicianDate of VisitPhysician

Vision RXVision RX

U. Dental Health

Date of VisitDentistProblemsResolution