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Medical Manager


                          Always try to keep your medical information updated.
                             You can print this and use as a template.
Current Medical Problems :[eg: hypertension, diabetes, cholesterol]
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Past Medical History : [eg: pneumonia, stroke, coronary artery disease]
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Previous Surgical Procedures : [eg: appendix, gallbladder]
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Current Medications plus dose and frequency : 
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Drug Allergies :[eg: penicillin, sulfa]
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Other Allergies : [eg : pollen, ragweed, latex]
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Family Medical History : [eg : colon cancer, breast cancer, diabetes, stroke, heart disease]
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  •  Parents, grandparents and siblings        
Immunization History : [eg: tetanus, pneumonia]

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Test Results : [eg: cholesterol, complete blood count]
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Major Studies : [eg: stress test, colonoscopy, mammogram]
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My measurable data : [Age, Height, Weight, Blood Pressure, Cholesterol levels]

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My health care proxy is:                           tel:

My emergency contact is:                         tel: 

My wishes with regard to resuscitation and life support are:

My wishes with regard to organ donation are:

My pharmacy telephone number is:

My doctor is:                          tel:              ann. exam month:

My ob/gyn is:                        tel:              ann. exam month:

My eye doc. is:                       tel:              ann. exam month:  

My health insurance is:                                              number:

 

Reminders:

  • Immunizations (tetanus booster every 10 years with Tdap booster if in close contact with infants <1 year of age; annual flu shot; pneumonia vaccines (Prevnar-13 and Pneumovax-23 at ages 64 and 65; shingles vaccine at age 60)
  • Pap smear (start at 21 and then every 1-2 years depending on type of smear test done). No screening after 69.
  • Mammogram (baseline at age 40 and then annually from age 50, but family history must be taken into account)
  • Bone density  (baseline when at menopause, but definitely at age 65 and then repeat every two years)
  • Colonoscopy (baseline at age 50 if no family history of colon cancer). No screening after age 75.
  • PSA (prostate cancer screening) : controversial as to whether this actually saves lives, but current recommendation is to test between the ages of 55 and 69
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