SA Health

My Personal Health Folder

Name:

Developed by Statewide Rehabilitation Clinical Network

June 2015

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My personal informationThis section helps you to be able to fill out forms or answer questions that hospital or other staff may ask you.

Name

Date of birth / /

Address

Phone number/s

Medicare card number

Health Care Card number

Private Insurance details

I have Ambulance cover Yes No

My current GP is

Name

Address

Phone number

Emergency contacts (who do you want to be called in an emergency)

Name Phone number Relationship to you

My family

Mother/guardian

Phone number

Father/guardian

Phone number

Siblings

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My medical historyThis section includes important information that your medical teams may need to know, or that they may ask you about.

Birth weight

Any health issues at birth

Any allergies or sensitivities to medication, food or other things e.g. tapes

Medication, food or other Reaction – what happens when I am given/come in contact with this including what care I need

Significant health history event and/or hospitalisation as a child

Illness, event or hospitalisation Age at the time/date

Other relevant information e.g procedures, treatment

Significant surgeries as a child

Surgery Age at the time/date

Why I had this surgery

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Family medical historyThis section includes important information about your family’s medical history that your medical teams may need to know, or that they may ask you about.

Condition Relation to me

Cancer – include type

Diabetes

Heart disease

High blood pressure

Mental health – describe

Other:

Immunisation historyThis section includes important information about your immunisation history that your medical teams may need to know, or that they may ask you about. You can also add to this as you have further immunisations.

Immunisation Dates

Diphtheria, tetanus, whooping cough (DTP)

Polio (OPV or Sabin)

Hepatitis B

Measles, Mumps, Rubella (MMR)

Haemophilus Influenza type B (Hib)

Varicella (chicken pox)

Meningococcal C

Human Papillomavirus (HPV )

Flu

Other

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My current healthThis section should include the most up to date information about your current health for all your health teams to know and understand your health needs better.

Primary (main) diagnosis

Other relevant health information/diagnoses

Current medicationsThis section helps you to show the health teams the current medications you take, and can be added to at any time. If medications are ceased, write this in the date ceased column.

Medication Dose, including how often

Why I take this Date ceased

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My main hospital team are based at

My current adult team includes (This includes both hospital and community teams you are involved with. It includes medical, nursing and any allied health staff you see).

Their role Name Contact number

My paediatric team included

Their role Name Contact number

My current equipment needs from the hospital are

Equipment Supplied/serviced by

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A summary of my health care needsIf you think the medical teams need a more detailed summary of your health needs, this can be written here. You may want to include headings for your different areas of health needs or attach a health plan if you have one.

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More general information about me and my health needs

Some other important information that teams need to know, that will assist me:

(Tick any relevant information that the adult teams may need to know or fill in your own information that you think they need to know)

I need extra time to answer and understand what you are discussing with me

I need to write things down to remember

I need simple instructions

I need step by step instructions

I use a wheelchair to get around

I use a walker or other equipment to get around

Personal and other general care

Daily task I can do this myself

I need assistance with this

Other information about this

Getting dressed

Eating meals

Preparing meals/snacks

Having a shower/bath

Cleaning my teeth

Brushing my hair

Transferring

Making appointments

Getting my medication scripts filled

Providing my own health care needs

Seeing the doctors and other staff

Do you still want parents or others to attend with you for support?

Yes No

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Others that I receive care and assistance from include:

None

In home support from an agency or service

Family

Friends

Out of home respite

Other

My assistive devices include:

I don’t use any assistive devices

Manual wheelchair

Electric wheelchair

Walker

Crutches

Special needs dog

Lifting device

Augmentative Communication device (please describe)

Other (please describe)

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Upcoming appointmentsThis is a useful section to keep a record of your appointments with the adult teams. This can include any medical, nursing or allied health appointments as well as community appointments you may have. It may also help the staff to see who you are due to visit.

Appointment date

Appointment Time

Who is this with? Where do I go for this appointment?

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Monitoring my health This is a useful section to keep a record of your current and changing health with the adult teams. It may also help the staff to see your health history.

Health problem Date Results and any other comments

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Other attachments/relevant documents in my health folder In this section of the folder, file all the relevant referrals and summaries written by your paediatric teams to the doctors, nurses and allied health staff. This can include community referrals and discharge summaries, such as summaries from Novita.

For more information Clinical Practice ConsultantPaediatric Rehabilitation DepartmentWomen’s and Children’s Health Network72 King William RoadNorth Adelaide SA 5006 Telephone: 8161 7367

If you do not speak English, request an interpreter from SA Health and the department will make every effort to provide you with an interpreter in your language.

www.ausgoal.gov.au/creative-commons

© Department for Health and Ageing, Government of South Australia. All rights reserved. June 2015. (Digital Media 6547)